Extruded rice fortified with micronized ground ferric pyrophosphate reduces iron deficiency in Indian schoolchildren: a double-blind randomized controlled trial

Apparent amylose content positively influences the quality of extruded fortified rice kernels

The present research studies the impact of apparent amylose content (AAC) on the quality of fortified rice kernels (FRK), a health food designed to combat iron deficiency anemia by fortifying with iron, folic acid, and vitamin B12. Five FRK formulations with varying AAC (0.46-23.89 %) were prepared, and AAC influence on the extruder-system parameter and physicochemical, cooking, and textural properties of FRK was investigated. The torque, die-pressure, length, redness, and cooking time increased with an increase in AAC and were in the range of 12.55-22.81 Nm, 58.31-88.96 bar, 4.58-5.09 mm, 0.35-1.15, and 6.1-11.2 min, respectively. The other parameters, such as the breadth, whiteness index, and cooking loss decreased with an increase in AAC. Except for cohesiveness, all other textural properties of cooked FRK increased with an increase in AAC. These correlations of the FRK properties with AAC were confirmed through multivariate analysis. SEM, XRD, FTIR, and rheology supported the observed AAC trends in FRK properties. SEM showed a reduction in pores and cracks with an increase in AAC. The XRD and FTIR showed an increase in crystallinity with an increase in AAC due to better gelatinization leading to rapid retrogradation. This leads to better physical, cooking, and textural properties of FRK.

Is iron status associated with markers of non-communicable disease in adolescent Indian children?

BACKGROUND

High body iron status has been associated with non-communicable diseases (NCD) like diabetes (high fasting blood glucose, FBG), hypertension (HTN) or dyslipidaemia (high total cholesterol, TC) in adults, but this has not been examined in adolescent children. This is relevant to iron supplementation and food iron fortification programs that are directed at Indian children.

METHODS

The association of NCD with Serum Ferritin (SF) was examined using logistic additive models, adjusted for confounders such as age, body mass index, C-Reactive Protein, haemoglobin and sex, in adolescent (10-19 years old) participants of the Indian Comprehensive National Nutrition Survey. The interaction of these associations with wealth and co-existing prediabetes was also examined. A scenario analysis was also done to understand the impact of iron fortification of cereals on the prevalence NCD among adolescents.

RESULTS

The odds ratio (OR) of high FBG, HTN and TC were 1.05 (95% CI: 1.01-1.08), 1.02 (95% CI: 1.001-1.03) and 1.04 (95% CI: 1.01-1.06) respectively for every 10 µg/L increase in SF. The odds for high TC increased with co-existing prediabetes. The scenario analysis showed that providing 10 mg of iron/day by fortification could increase the prevalence of high FBG by 2-14% across states of India. Similar increments in HTN and TC can also be expected.

CONCLUSIONS

High SF is significantly associated with NCD in adolescents, dependent on wealth and co-existing prediabetes. This should be considered when enhancing iron intake in anaemia prevention programs, and the NCD relationship with body iron stores should be studied.

Effects of iron deficiency and iron supplementation at the host-microbiota interface: Could a piglet model unravel complexities of the underlying mechanisms?

Iron deficiency is the most prevalent human micronutrient deficiency, disrupting the physiological development of millions of infants and children. Oral iron supplementation is used to address iron-deficiency anemia and reduce associated stunting but can promote infection risk since restriction of iron availability serves as an innate immune mechanism against invading pathogens. Raised iron availability is associated with an increase in enteric pathogens, especially Enterobacteriaceae species, accompanied by reductions in beneficial bacteria such as Bifidobacteria and lactobacilli and may skew the pattern of gut microbiota development. Since the gut microbiota is the primary driver of immune development, deviations from normal patterns of bacterial succession in early life can have long-term implications for immune functionality. There is a paucity of knowledge regarding how both iron deficiency and luminal iron availability affect gut microbiota development, or the subsequent impact on immunity, which are likely to be contributors to the increased risk of infection. Piglets are naturally iron deficient. This is largely due to their low iron endowments at birth (primarily due to large litter sizes), and their rapid growth combined with the low iron levels in sow milk. Thus, piglets consistently become iron deficient within days of birth which rapidly progresses to anemia in the absence of iron supplementation. Moreover, like humans, pigs are omnivorous and share many characteristics of human gut physiology, microbiota and immunity. In addition, their precocial nature permits early maternal separation, individual housing, and tight control of nutritional intake. Here, we highlight the advantages of piglets as valuable and highly relevant models for human infants in promoting understanding of how early iron status impacts physiological development. We also indicate how piglets offer potential to unravel the complexities of microbiota-immune responses during iron deficiency and in response to iron supplementation, and the link between these and increased risk of infectious disease.

Ensuring the Efficacious Iron Fortification of Foods: A Tale of Two Barriers

Iron fortification of foods has always been a challenge. This is because iron fortification compounds vary widely in relative absorption; because many foods undergo unacceptable changes in color or flavor from the addition of iron; and because many of the iron-fortified foods contain potent inhibitors of iron absorption. These technical barriers have largely been overcome, and efficacious iron-fortified foods, that maintain or improve the iron status of women or children in long-term feeding studies, can be designed. Commercially fortified infant foods are efficacious, and other commercial iron-fortified foods targeted at women and children will provide a useful amount of iron provided the fortification level is adjusted according to the relative absorption of the iron compound. Technologies for the large-scale fortification of wheat and maize flour are also well established, and iron fortification of rice, using the recently developed extruded premix technique, is showing great promise. However, some important knowledge gaps still remain, and further research and development is needed in relation to iron (and iodine)-fortified salt and iron-fortified liquid milk. The usefulness of less-soluble iron compounds, such as ferrous fumarate, to fortify foods for infants and young children in low- and middle-income countries (LMICs) also needs further investigation. A more formidable barrier to efficacious iron-fortified food has been reported in recent years. This is the infection-initiated inflammation barrier, which inhibits iron absorption in response to infection. This barrier is particularly important in LMICs where infections such as malaria and HIV are widespread, and gastrointestinal infections are common due to poor quality water supplies and sanitation. Another source of inflammation in such countries is the high prevalence of obesity in women. Most countries in sub-Saharan Africa have high inflammation which not only decreases the efficacy of iron-fortified and iron-biofortified foods but complicates the monitoring of large-scale iron fortification programs. This is because iron deficiency anemia cannot be differentiated from the more prominent anemia of inflammation and because inflammation confounds the measurement of iron status. There is an urgent need to better quantify the impact of inflammation on the efficacy of iron-fortified foods. However, at present, in LMICs with high inflammation exposure, infection control, cleaner water, improved sanitation, and a decrease in obesity prevalence will undoubtedly have a greater impact on iron status and anemia than the iron fortification of foods.

A Natural Low Phytic Acid Finger Millet Accession Significantly Improves Iron Bioavailability in Indian Women

Iron deficiency and anemia are common in low- and middle-income countries. This is due to a poor dietary iron density and low iron absorption resulting from the high inhibitory phytic acid content in cereal and millet-based diets. Here, we report that a naturally occurring low phytic acid finger millet accession (571 mg 100 g⁻¹), stable across three growing seasons with normal iron content (3.6 mg 100 g⁻¹), increases iron absorption by 3-folds in normal Indian women. The accessions differing in grain phytic acid content, GE 2358 (low), and GE1004 (high) were selected from a core collection of 623 accessions. Whole genome re-sequencing of the accessions revealed significant single nucleotide variations segregating them into distinct clades. A non-synonymous mutation in the EcABCC phytic acid transporter gene between high and low accessions could affect gene function and result in phytic acid differences. The highly sensitive dual stable-isotope erythrocyte incorporation method was adopted to assess the fractional iron absorption. The low phytic acid accession resulted in a significantly higher iron absorption compared with the high phytic acid accession (3.7 vs. 1.3%, p < 0.05). The low phytic acid accession could be effective in preventing iron deficiency in regions where finger millet is habitually eaten. With its low water requirement, finger millet leaves low environmental footprints and hence would be an excellent sustainable strategy to mitigate iron deficiency.

Rice as a vehicle for micronutrient fortification: a systematic review of micronutrient retention, organoleptic properties, and consumer acceptability

CONTEXT

Previous reviews have focused on evaluating the efficacy and effectiveness of rice fortification, despite the need to also understand the outcomes of micronutrient retention, organoleptic properties, and acceptability to inform nutrition programs.

OBJECTIVE

This systematic review aims to consolidate existing evidence on micronutrient retention, organoleptic properties, and acceptability of fortified rice.

DATA SOURCES

Eligible articles were identified from 22 electronic databases and personal referrals and reviews.

STUDY SELECTION

Studies on rice fortified via extrusion or coating technologies were included in the review if they reported outcomes in at least 1 of 3 domains: micronutrient retention, organoleptic or physicochemical properties, and acceptability (evaluated by sensory tests and consumer surveys). Any years of publication and study populations were considered for inclusion. A total of 15 391 articles were screened, yielding 49 for inclusion.

DATA EXTRACTION

Study results were summarized descriptively through discussions by intervention conditions, study population, measurement methods, and key findings. The included studies were independently reviewed by 2 of the 3 authors, and all 3 authors reached consensus on the quality and major findings from the included articles.

RESULTS

Extrusion and coating fortification technologies were found to be comparable across studies that assessed retention, organoleptic properties, and acceptability. Cooking fortified rice in excess water increased micronutrient loss for both technologies. Fortified kernels containing ferric pyrophosphate, zinc oxide, or zinc sulfate showed the most positive results for all outcomes reviewed, while retention rates of vitamin A in multiple-micronutrient-fortified rice were variable.

CONCLUSIONS

The current practice of fortifying rice with ferric pyrophosphate provides high micronutrient stability and results in rice with organoleptic properties and consumer acceptance levels comparable to those of unfortified milled rice, although it presents challenges regarding the effect of vitamin A-fortified rice on vitamin A status.

Consumption of Sinlek Rice Drink Improved Red Cell Indices in Anemic Elderly Subjects

Iron fortifications are used for the treatment of iron-deficiency anemia; however, iron dosing may cause oxidative damage to the gut lumen. Thai Sinlek rice is abundant in iron and contains phytochemicals. We aimed at evaluating the effect of an iron-rice (IR) hydrolysate drink (100 mL/serving) on neurological function, red cell indices and iron status in elders. Healthy elderly subjects were divided into three non-anemic groups and one anemic group. The non-anemic groups consumed one WR (2 mg iron/serving) and two IR drinks (15 and 27 mg iron/serving) (groups A, B and D, respectively), while the anemic group consumed one IR drink (15 mg iron serving) (group C) every day for 30 days. There were no significant differences in the MMSE Thai 2002 and PHQ9 test scores for members of all groups, while the nutrition scores and body weight values of group D subjects were significantly increased. Hemoglobin (Hb) and mean corpuscular hemoglobin concentrations increased significantly only in group C. Serum iron and transferrin saturation levels tended to increase in group A, while these levels were decreased in members of group C. Serum antioxidant activity levels were increased in all groups, and were highest in group C. Thus, consumption of an IR drink for 15 days functioned to increase Hb and antioxidant capacity levels in anemic elders.

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

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

Prevalence and approaches to manage iron deficiency anemia (IDA)

Iron is a vital micronutrient required for growth and development at all stages of human life. Its deficiency is the primary cause of anemia that poses a significant global health problem and challenge for developing countries. Various risks are involved during iron deficiency anemia (IDA), such as premature delivery, low birth weight, etc. Further, it affects children's cognitive functioning, delays motor development, hampers physical performance and quality of life. It also speeds up the morbidity and mortality rate among women. The major reasons accountable are elevated iron demand in diet, socio-economic status, and disease condition. Various strategies have been adopted to reduce the IDA occurrence, such as iron supplementation, iron fortificants salts, agronomic practices, dietary diversification, biofortification, disease control measures, and nutritional education. Usually, the staple food groups for fortification are considered, but the selection of food fortificants and their combination must be safe for the consumers and not alter the finished product's stability and acceptability. Genetically modified breeding practices also increase the micronutrient levels of cereal crops. Therefore, multiple strategies could be relied on to combat IDA.

Effect of hepcidin antagonists on anemia during inflammatory disorders

Iron is an essential element for the mammalian body however, its homeostasis must be regulated accurately for appropriate physiological functioning. Alterations in physiological iron levels can lead to moderate to severe iron disorders like chronic and acute iron deficiency (anemia) or iron overload. Hepcidin plays an important role in regulating homeostasis between circulating iron and stored iron in the cells as well as the absorption of dietary iron in the intestine. Inflammatory disorders restrict iron absorption from food due to increased circulating levels of hepcidin. Increased production of hepcidin causes ubiquitination of ferroportin (FPN) leading to its degradation, thereby retaining iron in the spleen, duodenal enterocytes, macrophages, and hepatocytes. Hepcidin inhibitors and antagonists play a consequential role to ameliorate inflammation-associated anemia. Many natural and synthesized compounds, able to reduce hepcidin expression during inflammation have been identified in recent years. Few of which are currently at various phases of clinical trial. This article comprises a comprehensive review of therapeutic approaches for the efficient treatment of anemia associated with inflammation. Many strategies have been developed targeting the hepcidin-FPN axis to rectify iron disorders. Hepcidin modulation with siRNAs, antibodies, chemical compounds, and plant extracts provides new insights for developing advanced therapeutics for iron-related disorders. Hepcidin antagonist's treatment has a high potential to improve iron status in patients with iron disorders, but their clinical success needs further recognition along with the identification and application of new therapeutic approaches.

Supplementation with >Your< Iron Syrup Corrects Iron Status in a Mouse Model of Diet-Induced Iron Deficiency

The objective of this study was to compare the effects of >Your< Iron Syrup, a novel oral liquid iron-containing food supplement, with the commonly prescribed iron sulphate (Fe-sulphate) in a mouse model of diet-induced iron deficiency. Standard inbred BALB/cOlaHsd mice were fed low-iron diet for 11 weeks to induce significant decrease in blood haemoglobin and haematocrit and were then supplemented by gavage with either >Your< Iron Syrup or Fe-sulphate for two weeks. In >Your< Iron Syrup group, several markers of iron deficiency, such as serum iron concentration, transferrin saturation and ferritin level were significantly improved in both female and male mice. Fe-sulphate induced similar responses, except that it did not significantly increase iron serum in females and serum ferritin in both sexes. Fe-sulphate significantly increased liver-iron content which >Your< Iron Syrup did not. Transcription of Hamp and selected inflammatory genes in the liver was comparable between the two supplementation groups and with the Control diet group. Some sex-specific effects were noted, which were more pronounced and less variable in males. In conclusion, >Your< Iron Syrup was efficient, comparable and in some parameters superior to Fe-sulphate in improving iron-related parameters without inducing a response of selected liver inflammation markers in a mouse model of diet-induced iron deficiency.

Micronized, Microencapsulated Ferric Iron Supplementation in the Form of >Your< Iron Syrup Improves Hemoglobin and Ferritin Levels in Iron-Deficient Children: Double-Blind, Randomized Clinical Study of Efficacy and Safety

A major problem of oral iron supplementation efficacy in children is its tolerability and compliance. We aimed to determine the safety and efficacy of a novel food supplement >Your< Iron Syrup in the replenishment of iron stores and improvement of hematological parameters in iron-deficient children aged nine months to six years. We randomized 94 healthy children with iron deficiency in a ratio of 3:1 to either receive >Your< Iron Syrup or placebo. A 12-week supplementation with >Your< Iron Syrup resulted in a significant increase in ferritin and hemoglobin levels as compared to placebo (p = 0.04 and p = 0.02). Adverse events were reported with similar frequencies across both study arms. >Your< Iron Syrup represents an effective, well-tolerated, and safe option for the management of nutritional iron deficiency in children.

Considerations for improvising fortified extruded rice products

Micronutrient fortification of rice by extrusion is an effective strategy to enhance micronutrient levels within rice-consuming individuals. The success of extrusion-based fortification is associated with micronutrient retention, enhanced bioavailability, low postprocessing losses, prolonged storage stability, and minimal sensory changes. The success of an optimally fortified product is primarily reliant upon the compositional considerations, but many attributes of extrudates can be indebted to the processing parameters too. Hence, an exhaustive investigation of this technology has been taken-up here, emphasizing on the compositional parameters in association with process parameters, which influence the final quality attributes like nutrient stability, bioavailability, and sensory properties. Based on these attributes of the end product, a collected data have been presented here to bring out the optimal compositional requirements. These together with cooking processes, extrusion process parameters, and storage conditions will enable formulate a product with enhanced sensory acceptance, better retention during cooking and storage, improved texture, and acceptable color. This review will thus help to optimize a need-based product, its quality, and enhance benefits of fortified extruded rice products.

Iron Fortification Practices and Implications for Iron Addition to Salt

This introductory article provides an in-depth technical background for iron fortification, and thus introduces a series of articles in this supplement designed to present the current evidence on the fortification of salt with both iodine and iron, that is, double-fortified salt (DFS). This article reviews our current knowledge of the causes and consequences of iron deficiency and anemia and then, with the aim of assisting the comparison between DFS and other common iron-fortified staple foods, discusses the factors influencing the efficacy of iron-fortified foods. This includes the dietary and physiological factors influencing iron absorption; the choice of an iron compound and the fortification technology that will ensure the necessary iron absorption with no sensory changes; encapsulation of iron fortification compounds to prevent unacceptable sensory changes; the addition of iron absorption enhancers; the estimation of the iron fortification level for each vehicle based on iron requirements and consumption patterns; and the iron status biomarkers that are needed to demonstrate improved iron status in populations regularly consuming the iron-fortified food. The supplement is designed to provide a summary of evidence to date that can help advise policy makers considering DFS as an intervention to address the difficult public health issue of iron deficiency anemia, while at the same time using DFS to target iodine deficiency.

The Potential of Iodine and Iron Double-Fortified Salt Compared with Iron-Fortified Staple Foods to Increase Population Iron Status

The potential of double-fortified salt (DFS) to improve population iron status is compared with the potential of iron-fortified wheat flour, maize flour, rice grains, and milk products. The potential for a positive impact on iron status is based on reported efficacy studies, consumption patterns, the extent of industrialization, and whether there are remaining technical issues with the fortification technologies. Efficacy studies with DFS, and with iron-fortified wheat flour, maize flour, and rice, have all reported good potential to improve population iron status. Iron-fortified milk powder has shown good impact in young children. When these foods are industrially fortified in modern, automated facilities, with high-level quality control and assurance practices, high-quality raw materials, and a wide population coverage, all vehicles have good potential to improve iron status. Relative to other fortification vehicles, fortification practices with wheat flour are the most advanced and iron-fortified wheat flour has the highest potential for impact in the short- to medium-term in countries where wheat flour is consumed as a staple. Liquid milk has the least potential, mainly because an acceptable iron fortification technology has not yet been developed. Maize is still predominantly milled in small-scale local mills and, although the extruded rice premix technology holds great promise, it is still under development. Salt has a proven record as an excellent vehicle for iodine fortification and has demonstrated good potential for iron fortification. However, technical issues remain with DFS and further studies are needed to better understand and avoid color formation and iron-catalyzed iodine losses in both high- and low-quality salts under different storage conditions. There is currently a risk that the introduction of DFS may jeopardize the success of existing salt iodization programs because the addition of iron may increase iodine losses and cause unacceptable color formation.

Micronutrient-fortified rice improves haemoglobin, anaemia prevalence and cognitive performance among schoolchildren in Gujarat, India: a case-control study

Anaemia is a public health problem in India. A case-control, quasi-experimental study was conducted to evaluate the effect of a multiple micronutrient fortified rice intervention among school children (6-12 years) through the midday meal programme in Gujarat, India, over 8 months. The fortified rice provided approximately 10% Recommended Dietary Allowance of iron; 25-33% of vitamin A, thiamine, niacin and vitamin B6; and 100% of folic acid and vitamin B12. Outcomes of interest included haemoglobin concentration, anaemia prevalence, and cognitive performance. Cognitive performance was evaluated using J-PAL-validated Pratham reading and mathematics testing tools. 973 children completed the study (cases n = 484; controls n = 489). The intervention significantly increased mean haemoglobin by 0.4 g/dL (p = 0.001), reduced anaemia prevalence by 10% (p < 0.00001), and improved average cognitive scores by 11.3 points (p < 0.001). Rice fortification can help address anaemia in settings where rice is a staple food.

High dietary micronutrient inadequacy in peri-urban school children from a district in South India: Potential for staple food fortification and nutrient supplementation

Multiple micronutrient deficiencies (MNDs) co-exist, often because of poor intakes and adversely impact health. Habitual diets were assessed in 300 school children (6-17 years old) recruited from two government schools by simple random sampling. Probability of adequacy (PA) for 11 micronutrients and mean probability of adequacy (MPA) was calculated. Haemoglobin, plasma ferritin, folic acid, vitamin B12 and C-reactive protein were estimated. Descriptive statistics and regression analysis were used to estimate magnitude and factors associated with MNDs. The contribution of fortified foods and/or supplements in addressing inadequacies and excessive intakes was modelled. The PA ranged from 0.04 for folate to 0.70 for zinc, and the MPA was 0.27. Prevalence of anaemia (53%), iron deficiency (57%; ID), iron deficiency anaemia (38%; IDA), folate deficiency (24%) and B12 deficiency (43%) was high. Dietary inadequacy of iron, zinc and a low MPA was associated with anaemia and IDA. Inclusion of double fortified salt (DFS), fortified rice (FR) or iron folic acid (IFA) supplements individually in habitual diet reduced probability of iron inadequacy significantly from 82% to ≤13%. Inclusion of DFS and FR simultaneously led to disappearance of iron inadequacy, but risk of excessive intake increased to 16%. Inclusion of DFS, FR and IFA together increased risk of excess iron intake to 40%. Nevertheless, intakes of folate and B12 remained inadequate even with FR and/or IFA. These results indicate a high risk of dietary MNDs in children and suggest need for more systematic intake measurements in representative sample and adjustment of iron dosages to avoid excessive intakes.

Retention, stability, iron bioavailability and sensory evaluation of extruded rice fortified with iron, folic acid and vitamin B12

Fortification of rice with micronutrients using extrusion technology is considered a sustainable strategy to prevent nutritional deficiencies in general population. The objective of the present study is to assess the retention, stability and iron bioavailability from indigenously developed triple fortified rice (iron, folic acid and vitamin B12 ) during rinsing and different cooking methods. Further, we also assessed the acceptability of fortified rice in adult human volunteers. The retention of iron during rinsing with excess water was ≥90%, whereas folic acid and vitamin B12 levels were reduced by ~25% during rinsing. Watertight cooking of rice (in electric cooker or on flame) had no additional effect on the nutrient levels as compared with rinsed rice, implying their stability during cooking. However, cooking with excess water followed by decanting led to loss of 45% iron and ≥70% folic acid and vitamin B12 . The dialyzable iron and ferritin synthesis in Caco-2 cells was significantly (P < .01) higher from fortified rice compared with unfortified rice. In addition, inclusion of ascorbic acid significantly (P < .01) increased the iron bioavailability from the fortified rice. Triangle tests in adult human subjects revealed that there are no significant sensory differences among fortified and unfortified rice. Further, fortified rice consumption appears to bridge the gaps in dietary iron intake deficits in children and women of reproductive age. These results suggest that the iron-, folic acid- and vitamin B12 -fortified rice has higher retention and stability of fortified nutrients and is acceptable for consumption in adult human volunteers.

Equity implications of rice fortification: a modelling study from Nepal

Objective:

To model the potential impact and equity impact of fortifying rice on nutritional adequacy of different subpopulations in Nepal.

Design:

Using 24-h dietary recall data and a household consumption survey, we estimated: rice intakes; probability of adequacy (PA) of eight micronutrients commonly fortified in rice (vitamin A, niacin (B₃), pyridoxine (B₆), cobalamin (B₁₂), thiamin (B₁), folate (B₉), Fe and Zn) plus riboflavin (B₂), vitamin C and Ca and mean probability of adequacy (MPA) of these micronutrients. We modelled: no fortification; fortification of purchased rice, averaged across all households and in rice-buying households only. We compared adequacy increases between population subgroups.

Setting:

(i) Dhanusha and Mahottari districts of Nepal (24-h recall) and (ii) all agro-ecological zones of Nepal (consumption data).

Participants:

(i) Pregnant women (n 128), mothers-in-law and male household heads; (ii) households (n 4360).

Results:

Unfortified diets were especially inadequate in vitamins B₁₂, A, B_9, Zn and Fe. Fortification of purchased rice in rice-purchasing households increased PA > 0·9 for thiamin, niacin, B₆, folate and Zn, but B₁₂ and Fe remained inadequate even after fortification (PA range 0·3–0·9). Pregnant women’s increases exceeded men’s for thiamin, niacin, B₆, folate and MPA; men had larger gains in vitamin A, B₁₂ and Zn. Adequacy improved more in the hills (coefficient 0·08 (95 % CI 0·05, 0·10)) and mountains (coefficient 0·07 (95 % CI 0·01, 0·14)) but less in rural areas (coefficient −0·05 (95 % CI −0·09, −0·01)).

Conclusions:

Consumption of purchased fortified rice improves adequacy and gender equity of nutrient intake, especially in non-rice-growing areas.

Efficacy of an iron-fortified infant cereal to reduce the risk of iron deficiency anemia in young children in East Cameroon

Complementary foods in Africa are often poor sources of bioavailable iron. We assessed the efficacy of iron-fortified wheat-based infant cereal (IC) to reduce the risk of iron deficiency anemia in children aged 18-59 months in Cameroon. A 6-month double-blind, cluster-randomized controlled trial was conducted in 2017 among anemic (hemoglobin 7-11 g/dl) but otherwise healthy children. In conjunction with usual diet, children received two 50 g servings/day of a standard, micronutrient-fortified IC (providing 3.75 mg iron/serving; n = 106) or the same IC without iron fortification (n = 99). Anthropometric measurements, blood sampling, and systematic deworming were performed in all children at baseline (pre-intervention), 3, and 6 months. Mean hemoglobin, ferritin adjusted for C-reactive protein (CRP), serum iron, transferrin saturation, prevalence of anemia, iron deficiency, and iron deficiency anemia as well as anthropometrics were compared between the groups at baseline, 3, and 6 months. Compared to the control group, children consuming the iron-fortified IC had significantly higher baseline-adjusted mean hemoglobin (10.0 ± 1.8 vs. 9.7 ± 1.4 g/dl, respectively; p = .023), ferritin adjusted for CRP (16.1 ± 8.3 vs. 9.5 ± 7.5 μg/L, p < .001), serum iron (14.5 ± 3.9 vs. 11.2 ± 4.4 μg/dl; p < .001), and transferrin saturation (19.0 ± 17.4 vs. 10.7 ± 12.5%; p ˂ .001) at 6 months. The prevalence of anemia, iron deficiency, and iron deficiency anemia at 6 months decreased by a larger extent in the iron-fortified group versus controls (all p < .01). In addition, at 6 months, children in the iron-fortified group demonstrated higher weight-for-age z-scores (p = .016) compared to the control group. Wheat-based IC fortified with 7.5 mg ferrous fumarate administered daily for 6 months improved iron and nutritional status and decreased the prevalence of iron deficiency anemia in children aged 18-59 months in Salapoumbé, Cameroon.

Iron Absorption from Bouillon Fortified with Iron-Enriched Aspergillus oryzae Is Higher Than That Fortified with Ferric Pyrophosphate in Young Women

BACKGROUND

Bouillon cubes are a potential vehicle for iron fortification. They are currently fortified with ferric pyrophosphate (FePP), which is known to be poorly absorbed. The objective of this study was to assess the iron absorption of Aspergillus oryzae grown in FePP (ASP-p) and compare it with FePP and ferrous sulfate (FeSO4)-fortified bouillon cubes.

METHODS

In 2 single-blinded, crossover studies, healthy women with serum ferritin concentrations <40 μg/L were randomly assigned to consume a rice-vegetable meal with iron-fortified chicken bouillon. Subjects in study I (n = 17, 18-26 y) consumed iron from both iron sources as 57FePP and 58ASP-p (intrinsically labeled with 58FePP) with a meal containing 4.2 mg of total iron provided for 3 d. Study II (n = 18, 18-29 y) was similar except that subjects consumed 57FeSO4 and 58ASP-p. Whole-blood stable isotope enrichment after 14 d was used to measure fractional iron absorption. Hemoglobin, hematocrit, serum ferritin, hepcidin, and serum C-reactive protein were analyzed at baseline and at 14 d. A t test was used to compare the mean differences in fractional absorptions within each study and baseline characteristics between studies.

RESULTS

Geometric mean (95% CI) fractional iron absorption of FePP [0.94% (0.63%, 1.40%)] was lower than ASP-p [2.20% (1.47%, 3.30%)] (P < 0.0001) in study I. In study II, ASP-p fractional absorption [2.98% (2.03%, 4.38%)] was lower than that of FeSO4 [9.88% (6.70%, 14.59%)] (P < 0.0001). Both ferritin (r = -0.41, P = 0.014) and hepcidin (r = -0.42, P = 0.01) concentrations were inversely correlated with ASP-p iron absorption. Fractional absorption of ASP-p was also positively correlated with FePP (r = 0.92, P < 0.0001) and FeSO4 (r = 0.52, P < 0.02) absorption.

CONCLUSIONS

ASP-p-fortified bouillon provided 2.3-fold higher absorbable iron than the currently used FePP. Bouillon fortified with ASP-p may contribute sufficient bioavailable iron to meet the daily iron requirements in young women only if consumed with other iron-fortified staple foods. This trial was registered at clinicaltrials.gov as NCT03586245.

Can School Feeding Programs Reduce Malnutrition in Rural China?

BACKGROUND

Childhood malnutrition is commonplace among poor rural communities in China. In 2012, China launched its first nationwide school-feeding program (SFP) to address this problem. This study examines the prevalence of malnutrition before and after the SFP and identifies possible reasons for the trends observed.

METHODS

Ordinary least squares regression and propensity score matching were used to analyze data from 2 cross-sectional surveys of 100 rural primary schools in northwestern China. Participants were fourth-and fifth-grade students. Outcome measures include anemia rates, hemoglobin levels, body mass index, and height for age Z scores.

RESULTS

Three years after implementation of the SFP, malnutrition rates among sample students had not fallen. The SFP had no statistically significant effect on either anemia rates or BMI, but was linked to an increase in the proportion of students with below normal height for age Z scores. Meals provided to students fell far short of national recommendations that the SPF should provide 40% of the recommended daily allowance of micronutrients.

CONCLUSIONS

Despite significant budgetary outlays between 2012 and 2015, China's SFP has not reduced the prevalence of malnutrition among sample students. To make the SFP more effective, funding and human resources both need to be increased.

Iron bioavailability of a casein-based iron fortificant compared with that of ferrous sulfate in whole milk: a randomized trial with a crossover design in adult women

BACKGROUND

A highly soluble iron-casein complex has been developed for food fortification purposes with the aim to provide high iron bioavailability.

OBJECTIVE

We aimed to determine the iron bioavailability of the iron-casein complex relative to that of ferrous sulfate (control) when given with whole milk in healthy young women.

METHODS

A randomized comparator-controlled trial with a crossover design was conducted using the erythrocyte incorporation dual stable isotope (57Fe, 58Fe) technique. Iron absorption from the iron-casein complex was compared with that from ferrous sulfate in 21 healthy women aged 20-38 y with normal iron status.

RESULTS

Fractional iron absorption (geometric mean; -SD, +SD) from the iron-casein complex (3.4%; 1.4%, 5.4%) and from ferrous sulfate (3.9%; 1.7%, 6.1%) were not statistically different (P > 0.05). The relative bioavailability value of the iron-casein complex to ferrous sulfate was determined to be 0.87 (-1 SD, +1 SD: -0.90, +2.64).

CONCLUSIONS

The iron-casein complex has iron bioavailability comparable to that of ferrous sulfate in healthy young women. This trial was registered at www.anzctr.org.au as ACTRN12615000690550.

Fortification of rice with vitamins and minerals for addressing micronutrient malnutrition

BACKGROUND

Rice fortification with vitamins and minerals has the potential to increase the nutrition in rice-consuming countries where micronutrient deficiencies exist. Globally, 490 million metric tonnes of rice are consumed annually. It is the dominant staple food crop of around three billion people.

OBJECTIVES

To determine the benefits and harms of rice fortification with vitamins and minerals (iron, vitamin A, zinc or folic acid) on micronutrient status and health-related outcomes in the general population.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, and 16 other databases all up to 10 December 2018. We searched ClinicalTrials.gov, and World Health Organization International Clinical Trials Registry Platform (ICTRP) on 10 December 2018.

SELECTION CRITERIA

We included randomised and quasi-randomised trials (with either individual or cluster randomisation) and controlled before-and-after studies. Participants were populations older than two years of age (including pregnant women) from any country. The intervention was rice fortified with at least one micronutrient or a combination of several micronutrients (iron, folic acid, zinc, vitamin A or other vitamins and minerals) compared with unfortified rice or no intervention.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently screened studies and extracted data.

MAIN RESULTS

We included 17 studies (10,483 participants) and identified two ongoing studies. Twelve included studies were randomised-controlled trials (RCTs), with 2238 participants after adjusting for clustering in two cluster-RCTs, and five were non-randomised studies (NRS) with four controlled before-and-after studies and one cross-sectional study with a control (8245 participants). Four studies were conducted in India, three in Thailand, two in the Philippines, two in Brazil, one each in Bangladesh, Burundi, Cambodia, Indonesia, Mexico and the USA. Two studies involved non-pregnant, non-lactating women and 10 involved pre-school or school-age children. All 17 studies reported fortification with iron. Of these, six studies fortified rice with iron only; 11 studies had other micronutrients added (iron, zinc and vitamin A, and folic acid). One study had one arm each with vitamin A alone and carotenoid alone. Elemental iron content ranged from 0.2 to 112.8 mg/100 g uncooked rice given for a period varying from two weeks to 48 months. Thirteen studies did not clearly describe either sequence generation or allocation concealment. Eleven studies had a low attrition rate. There was no indication of selective reporting in the studies. We considered two RCTs at low overall risk of bias and 10 at high overall risk of bias. One RCT was at high or unclear risk of bias for most of the domains. All controlled before-and-after studies had a high risk or unclear risk of bias in most domains. The included studies were funded by Government, private and non-governmental organisations, along with other academic institutions. The source of funding does not appear to have altered the results. We used the NRS in the qualitative synthesis but we excluded them from the quantitative analysis and review conclusions since they provided mostly contextual information and limited quantitative information. Rice fortified with iron alone or in combination with other micronutrients versus unfortified rice (no micronutrients added) Fortification of rice with iron (alone or in combination with other micronutrients) may make little or no difference in the risk of having anaemia (risk ratio (RR) 0.72, 95% confidence interval (CI) 0.54 to 0.97; I² = 74%; 7 studies, 1634 participants; low-certainty evidence) and may reduce the risk of iron deficiency (RR 0.66, 95% CI 0.51 to 0.84; 8 studies, 1733 participants; low-certainty evidence). Rice fortification may increase mean haemoglobin (mean difference (MD) 1.83, 95% CI 0.66 to 3.00; I² = 54%; 11 studies, 2163 participants; low-certainty evidence) and it may make little or no difference to vitamin A deficiency (with vitamin A as one of the micronutrients in the fortification arm) (RR 0.68, 95% CI 0.36 to 1.29; I² = 37%; 4 studies, 927 participants; low-certainty evidence). One study reported that fortification of rice (with folic acid as one of the micronutrients) may improve serum or plasma folate (nmol/L) (MD 4.30, 95% CI 2.00 to 6.60; 215 participants; low-certainty evidence). One study reported that fortification of rice with iron alone or with other micronutrients may slightly increase hookworm infection (RR 1.78, 95% CI 1.18 to 2.70; 785 participants; low-certainty evidence). We are uncertain about the effect of fortified rice on diarrhoea (RR 3.52, 95% CI 0.18 to 67.39; 1 study, 258 participants; very low-certainty evidence). Rice fortified with vitamin A alone or in combination with other micronutrients versus unfortified rice (no micronutrients added) One study had one arm providing fortified rice with vitamin A only versus unfortified rice. Fortification of rice with vitamin A (in combination with other micronutrients) may increase mean haemoglobin (MD 10.00, 95% CI 8.79 to 11.21; 1 study, 74 participants; low-certainty evidence). Rice fortified with vitamin A may slightly improve serum retinol concentration (MD 0.17, 95% CI 0.13 to 0.21; 1 study, 74 participants; low-certainty evidence). No studies contributed data to the comparisons of rice fortification versus no intervention. The studies involving folic acid and zinc also involved iron in the fortification arms and hence we reported them as part of the first comparison.

AUTHORS' CONCLUSIONS

Fortification of rice with iron alone or in combination with other micronutrients may make little or no difference in the risk of having anaemia or presenting iron deficiency and we are uncertain about an increase in mean haemoglobin concentrations in the general population older than 2 years of age. Fortification of rice with iron and other micronutrients such as vitamin A or folic acid may make little or no difference in the risk of having vitamin A deficiency or on the serum folate concentration. There is limited evidence on any adverse effects of rice fortification.

Consumption of rice, acceptability and sensory qualities of fortified rice amongst consumers of social safety net rice in Nepal

Introduction

Micronutrient deficiencies are prevalent in Nepal where starchy foods constitute a large proportion of diets and consumption of micronutrient-rich foods is inadequate. We conducted a study to determine whether rice would be an appropriate vehicle for micronutrient fortification in Nepal.

Materials and methods

In Bajura in remote rural Nepal, we conducted a household survey to characterize rice intakes in 195 households, and a double-blinded acceptability test with 177 social safety net rice consumers ≥18 years of age. Of these, 168 tasted fortified and unfortified rice to assess whether respondents could differentiate between fortified and non-fortified rice and their sensory properties. Rice was fortified by blending hot extruded kernels containing 6 micronutrients together with non-fortified rice at a 1:99 ratio. We used binomial tests to assess whether participants could correctly differentiate fortified rice, from non-fortified rice and paired t-tests to compare scores for sensory qualities of cooked fortified and non-fortified rice. We used multiple regression to test associations between per capita consumption and age, gender, wealth and food security.

Results

Per capita consumption of rice (median 216g/day, IQR 144.0, 288.0) did not vary by wealth but was +52.08g, (95% CI 10.43, 93.72) higher amongst moderately to severely food insecure households compared with food secure / mildly food insecure. Most respondents could not differentiate fortified rice from non-fortified rice: 37.5% identified uncooked fortified rice and 39.3% cooked rice, which was not different from the 33% expected by chance (p = 0.22 and p = 0.09 respectively). The sensory qualities of fortified rice were acceptable (scoring 3.9 out of 5) and did not differ from non-fortified rice (p>0.05).

Conclusion

A rice fortification programme implemented through the Nepal Food Corporation’s social safety nets has potential because purchase and consumption of rice is high and fortified rice is acceptable among consumers in remote food insecure areas of Nepal.

Interventions to Improve Micronutrient Status of Women of Reproductive Age in Southeast Asia: A Narrative Review on What Works, What Might Work, and What Doesn't Work

Objectives To provide an overview of nutrition-specific and nutrition-sensitive interventions that could improve micronutrient status of women of reproductive age. Methods This narrative review has a special focus on Southeast Asia, as the work was undertaken within the framework of the SMILING (Sustainable Micronutrient Interventions to controL deficiencies and Improve Nutrition status and General health in Southeast Asia) project. Results In order for new interventions to become accepted, comprehension and interpretation of potential impact of different strategies by policymakers and non-nutritionists is needed. By presenting a wide overview of strategies, and discussing the context and current consensus on these strategies, the review aims to help with the formulation of new recommendations for national programs in Southeast Asia. Conclusions Current policies in Southeast Asia to improve micronutrient status of women of reproductive age are focused too much on single micronutrient supplementation for pregnant women (iron and folic acid supplements). A more holistic approach, including both nutrition-specific and nutrition-sensitive interventions, is needed.

Beneficial Effects of ragi (Finger Millet) on Hematological Parameters, Body Mass Index, and Scholastic Performance among Anemic Adolescent High-School Girls (AHSG)

Adolescence is a period characterized by rapid physical, emotional, and mental growth and changes potentially resulting in health challenges. Anemia, which is a fairly common complication in this age group, is reported to negatively affect the cognitive ability of adolescents. Traditionally, ragi (Finger millet: Eleusine coracana), a cereal available in India, has been recommended as nutritional supplement to combat anemia because of its high protein and mineral content as well as anti-microbial property. This study sought to establish the effect of ragi in improving hematological parameters, body mass index, and scholastic performance among adolescent school girls. Sixty adolescent girls were randomly selected and divided into intervention (n = 30) and control groups (n = 30). The effect of dietary supplementation of ragi porridge on hematological parameters was evaluated on the intervention group at 45 and 90 days. Both groups were monitored for changes in body mass index and scholastic performance. A statistically significant increase in hemoglobin levels was observed in the intervention group after 90 days (from a mean of 11.3 g% to 12.54 g%; t ₍₂₉₎ = 7.514, p < .0001), with no significant changes in the control group. No statistically significant differences between the two groups were observed for mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, mean corpuscular volume, red cell distribution width, body mass index, and scholastic performance. The data show that daily dietary supplementation with ragi porridge has a positive effect on hemoglobin levels in adolescent high schools girls. A well planned nutrition education with dietary supplementation is thus recommended for better outcomes.

Cold Extrusion but Not Coating Affects Iron Bioavailability from Fortified Rice in Young Women and Is Associated with Modifications in Starch Microstructure and Mineral Retention during Cooking

Background: Rice can be fortified with the use of hot or cold extrusion or coating, but the nutritional qualities of the resulting rice grains have never been directly compared.Objective: Using fortified rice produced by coating or hot or cold extrusion, we compared 1) iron and zinc absorption with the use of stable isotopes, 2) iron and zinc retention during cooking, and 3) starch microstructure.Methods: We conducted 2 studies in young women: in study 1 [n = 19; mean ± SD age: 26.2 ± 3.4 y; body mass index (BMI; in kg/m²): 21.3 ± 1.6], we compared the fractional iron absorption (FAFe) from rice meals containing isotopically labeled ferric prophosphate (⁵⁷FePP), zinc oxide (ZnO), citric acid, and micronutrients fortified through hot extrusion (HER1) with rice meals fortified through cold extrusion containing ⁵⁷FePP, ZnO, citric acid, and micronutrients (CER); in study 2 (n = 22; age: 24 ± 4 y; BMI: 21.2 ± 1.3), we compared FAFe and fractional zinc absorption (FAZn) from rice meals fortified through hot extrusion (HER2) compared with rice meals fortified through coating containing ⁵⁷FePP, ZnO, a citric acid and trisodium cirate mixture (CA/TSC), and micronutrients (COR) relative to rice meals extrinsically fortified with ferrous sulfate (reference). Rice types HER1 and CER contained citric acid, whereas types HER2 and COR contained CA/TSC. We assessed retention during standardized cooking experiments and characterized the rice starch microstructure.Results: FAFe (95% CI) was greater from CER [2.2% (1.4%, 3.4%)] than from HER1 [1.2% (0.7%, 2.0%)] (P = 0.036). There was no difference in FAFe between HER2 [5.1% (3.7%, 7.1%)] and COR [4.0% (2.9%, 5.4%)] (P = 0.14), but FAFe from COR was lower than that from the reference meal [6.6% (4.9%, 9.0%)] (P = 0.003), and the geometric mean FAZn (95% CI) did not differ between HER2 [9.5% (7.9%, 11.6%)] and COR [9.6% (8.7%, 10.7%)] (P = 0.92). Cooking in a rice-to-water ratio of 1:2 resulted in iron and zinc retentions >80%, and cooking in excess water did not affect iron retention from hot-extruded rice but caused iron losses of 25% from CER and COR. Distinct variations in starch microstructure were found in CER and HER1.Conclusions: Iron absorption was 64% higher from CER than from hot-extruded rice, with no difference between COR compared with hot-extruded rice. Lower extrusion temperatures may generate a more readily digestible starch structure, allowing for greater iron release in vivo but lower mineral retention during cooking. This trial was registered at clinicaltrials.gov as NCT02176759.

Effect of multi-micronutrient-fortified rice on cognitive performance depends on premix composition and cognitive function tested: results of an effectiveness study in Cambodian schoolchildren

Objective

Even though current policy is strongly focused on the crucial first ‘1000 days’, it might be still possible to enhance cognitive function during the pre-adolescent and adolescent years by improving micronutrient status. In Cambodia, nutritional status is poor. Provision of rice fortified with micronutrients through a school meal programme (SMP) could be a cost-effective strategy to help improve health and school performance. The present study aimed to evaluate the effect of three different micronutrient-fortified rice formulations on cognitive function in Cambodian children.

Setting

Sixteen Cambodian schools receiving SMP.

Design

The FORISCA-UltraRice®+NutriRice®study was a randomized, double-blind, placebo-controlled trial. Four groups of four schools were randomly allocated to receive normal rice, UltraRice®Original, UltraRice®New or NutriRice®. Within each school, 132 children were randomly selected. Data on cognitive performance (picture completion, block design and Raven’s coloured progressive matrices (RCPM)), anthropometry, parasite infestation and micronutrient status were collected before the intervention and after 6 months.

Subjects

Cognitive data were available for 1796 children aged 6–16 years.

Results

All cognitive scores improved after 6 months (P<0·001). Block design score improvement was significantly higher in children consuming UltraRice®Original (P=0·03) compared with the other fortified rice groups and placebo. No difference among groups was found on RCPM or picture completion scores. Stunting, parasite infestation and inflammation negatively affected the impact of the intervention.

Conclusions

Combined with other interventions, using SMP to distribute fortified rice to schoolchildren may be a cost-effective way to increase cognitive performance and thereby improve school performance and educational achievements.

Mechanisms of Iron Uptake from Ferric Phosphate Nanoparticles in Human Intestinal Caco-2 Cells

Food fortification programs to reduce iron deficiency anemia require bioavailable forms of iron that do not cause adverse organoleptic effects. Rodent studies show that nano-sized ferric phosphate (NP-FePO₄) is as bioavailable as ferrous sulfate, but there is controversy over the mechanism of absorption. We undertook in vitro studies to examine this using a Caco-2 cell model and simulated gastrointestinal (GI) digestion. Supernatant iron concentrations increased inversely with pH, and iron uptake into Caco-2 cells was 2–3 fold higher when NP-FePO₄ was digested at pH 1 compared to pH 2. The size and distribution of NP-FePO₄ particles during GI digestion was examined using transmission electron microscopy. The d50 of the particle distribution was 413 nm. Using disc centrifugal sedimentation, a high degree of agglomeration in NP-FePO₄ following simulated GI digestion was observed, with only 20% of the particles ≤1000 nm. In Caco-2 cells, divalent metal transporter-1 (DMT1) and endocytosis inhibitors demonstrated that NP-FePO₄ was mainly absorbed via DMT1. Small particles may be absorbed by clathrin-mediated endocytosis and micropinocytosis. These findings should be considered when assessing the potential of iron nanoparticles for food fortification.

Dealing with iron metabolism in rice: from breeding for stress tolerance to biofortification

Iron is a well-known metal. Used by humankind since ancient times in many different ways, this element is present in all living organisms, where, unfortunately, it represents a two-way problem. Being an essential block in the composition of different proteins and metabolic pathways, iron is a vital component for animals and plants. That is why iron deficiency has a severe impact on the lives of different organisms, including humans, becoming a major concern, especially in developing countries where access to adequate nutrition is still difficult. On the other hand, this metal is also capable of causing damage when present in excess, becoming toxic to cells and affecting the whole organism. Because of its importance, iron absorption, transport and storage mechanisms have been extensively investigated in order to design alternatives that may solve this problem. As the understanding of the strategies that plants use to control iron homeostasis is an important step in the generation of improved plants that meet both human agricultural and nutritional needs, here we discuss some of the most important points about this topic.

Impact of rice fortified with iron, zinc, thiamine and folic acid on laboratory measurements of nutritional status of preschool children

Abstract Fortification of food constitutes an important strategy for the control of micronutrient deficiency and has advantages such as high population coverage and maintenance of eating habits. This study aimed to assess the impact of using fortified rice (Ultra Rice® - UR®) on the nutritional status of preschoolers. Ninety-nine children enrolled in two philanthropic preschools participated of the study. Children of one of the preschools were offered UR® mixed with polished rice, as part of school meals (test group) and the children of another preschool were offered pure polished rice (control group). Biochemical evaluations were performed before and after 4 months of intervention. Dietary assessment and sensory evaluation of UR® mixed with polished rice were performed during the study. The fortified rice improved the concentrations of zinc (p < 0.001), thiamine (p < 0.001), folic acid (p = 0.003), mean corpuscular hemoglobin (p < 0.001) and mean corpuscular hemoglobin concentration (p < 0.001). The fortified rice showed good acceptability among preschoolers. This study demonstrated the effectiveness of using rice fortified with iron, zinc, thiamine and folic acid on the nutritional status of children.

Iron Fortification: Its Efficacy and Safety in Relation to Infections

Iron-fortification programs are efficacious and effective provided recent guidelines are followed: the iron compound is carefully chosen and its level in the food is based on target population requirements, the amount lacking in the diet, and the iron bioavailability of the diet and the compound. For monitoring, serum ferritin and transferrin receptor should be included in addition to hemoglobin. Thus, recent studies of provision of iron-fortified salt to children in Morocco, rice to children in India, wheat flour to women in Thailand, and fish sauce in Vietnam have demonstrated efficacy and effectiveness. All were in nonmalarious areas, and intestinal parasites were uncommon except in India, where the children were dewormed. C-reactive protein was used to eliminate high ferritin values due to infection. An efficacy study of iron-fortified salt in dewormed school-aged children in Côte d'Ivoire, where the prevalence of malaria parasitemia was 55%, found no change in hemoglobin after 6 months, but serum ferritin increased and transferrin receptor decreased significantly, and the increase in body iron and estimated iron absorbed compared favorably with the results of a study of similar design in Morocco, where the prevalence of iron-deficiency anemia decreased from 30% to 5% after 10 months. Hence, iron-fortification programs in malarious areas may not decrease anemia prevalence but will improve iron status and, presumably, iron-dependent health outcomes. Eight studies in nonmalarious areas, all but one in infants receiving iron-fortified formula, have found no evidence of increase in infections and some evidence of a decrease in respiratory infection. There have been no studies in malarious areas.

An Assessment of the Potential Impact of Fortification of Staples and Condiments on Micronutrient Intake of Young Children and Women of Reproductive Age in Bangladesh

Bangladesh has experienced rapid economic growth and achieved major health improvements in the past decade, but malnutrition rates remain high. A nationally representative study conducted in 2011 assessed the dietary habits of 841 children 24-59 months old, 1428 children 6-14 years old, and 1412 nonpregnant, nonlactating women. The study's objective was to assess dietary intakes of key micronutrients and the consumption pattern of potentially fortifiable foods, and then to model the potential impact of the fortification of key staple foods. The current intakes of several micronutrients-namely, iron, zinc, folate, vitamin A, and vitamin B12-were found to be insufficient to meet the needs of Bangladesh's children and women. The fortification of rice with iron and zinc and edible oil with vitamin A has the potential to fill a significant part of the nutrient gap, as these are consumed widely and in significant amounts. Wheat flour and sugar are not as promising food vehicles in the Bangladeshi context, as they were consumed by a smaller portion of the population and in smaller amounts. In conclusion, fortification of rice and oil is recommended to address the large gap in micronutrient intakes.

Coverage of Adequately Iodized Salt Is Suboptimal and Rice Fortification Using Public Distribution Channels Could Reach Low-Income Households: Findings from a Cross-Sectional Survey of Anganwadi Center Catchment Areas in Telangana, India

Food fortification is a cost-effective approach to prevent and control of micronutrient deficiencies in India. A cross-sectional survey of children 0-35 months of age residing in the catchment areas of anganwadi centers in the state of Telangana was conducted to assess the coverage of adequately iodized salt and the potential for rice fortification. Salt samples were collected and tested for iodine concentration using iodometric titration. Information on demographics, household rice consumption, and Telangana's rice sector was collected and interpreted. In households of selected children, 79% of salt samples were found to be adequately iodized. Salt brand and district were significant predictors of inadequately iodized salt. Daily rice consumption among children and women averaged 122 grams and 321 grams per day, respectively. Approximately 28% of households reported consuming rice produced themselves or purchased from a local farmer, 65% purchased rice from a market or shop, 6% got rice from a public distribution system site, and 2% obtained it from a rice mill. In the catchment areas of Telangana's anganwadi centers, there is significant variation in the coverage of adequately iodized salt by district. Future surveys in Telangana should measure the coverage of salt iodization in the general population using quantitative methods. Nonetheless, increasing the adequacy of iodization of smaller salt manufacturers would help achieve universal salt iodization in Telangana. Despite high consumption of rice, our findings suggest that large-scale market-based rice fortification is not feasible in Telangana due to a large proportion of households producing their own rice and highly fragmented rice distribution. Distributing fortified rice via Telangana's public distribution system may be a viable approach to target low-income households, but would only reach a small proportion of the population in Telangana.

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.

Cofortification of ferric pyrophosphate and citric acid/trisodium citrate into extruded rice grains doubles iron bioavailability through in situ generation of soluble ferric pyrophosphate citrate complexes

BACKGROUND

Iron fortification of rice is a promising strategy for improving iron nutrition. However, it is technically challenging because rice is consumed as intact grains, and ferric pyrophosphate (FePP), which is usually used for rice fortification, has low bioavailability.

OBJECTIVE

We investigated whether the addition of a citric acid/trisodium citrate (CA/TSC) mixture before extrusion increases iron absorption in humans from FePP-fortified extruded rice grains.

DESIGN

We conducted an iron absorption study in iron-sufficient young women (n = 20), in which each participant consumed 4 different meals (4 mg Fe/meal): 1) extruded FePP-fortified rice (No CA/TSC); 2) extruded FePP-fortified rice with CA/TSC added before extrusion (CA/TSC extruded); 3) extruded FePP-fortified rice with CA/TSC solution added after cooking and before consumption (CA/TSC solution); and 4) nonextruded rice fortified with a FeSO4 solution added after cooking and before consumption (reference). Iron absorption was calculated from erythrocyte incorporation of stable iron isotopes 14 d after administration. In in vitro experiments, we assessed the soluble and dialyzable iron from rice meals in which CA/TSC was added at different preparation stages and from meals with different iron:CA:TSC ratios.

RESULTS

Fractional iron absorption was significantly higher from CA/TSC-extruded meals (3.2%) than from No CA/TSC (1.7%) and CA/TSC solution (1.7%; all P < 0.05) and was not different from the FeSO4 reference meal (3.4%). In vitro solubility and dialyzability were higher in CA/TSC-extruded rice than in rice with No CA/TSC and CA/TSC solution, and solubility increased with higher amounts of added CA and TSC in extruded rice.

CONCLUSIONS

Iron bioavailability nearly doubled when CA/TSC was extruded with FePP into fortified rice, resulting in iron bioavailability comparable to that of FeSO4 We attribute this effect to an in situ generation of soluble FePP citrate moieties during extrusion and/or cooking because of the close physical proximity of FePP and CA/TSC in the extruded rice matrix. This trial was registered at clinicaltrials.gov as NCT02176759.

Stability of Vitamin A, Iron and Zinc in Fortified Rice during Storage and Its Impact on Future National Standards and Programs--Case Study in Cambodia

Fortified rice holds great potential for bringing essential micronutrients to a large part of the world population. The present study quantified the losses of three different micronutrients (vitamin A, iron, zinc) in fortified rice that were produced using three different techniques (hot extrusion, cold extrusion, and coating) and stored at two different environments (25 ± 5 °C at a humidity of 60% and 40 ± 5 °C at a humidity of 75%) for up to one year. Fortified rice premix from the different techniques was mixed with normal rice in a 1:100 ratio. Each sample was analyzed in triplicate. The study confirmed the high stability of iron and zinc during storage while the retention of vitamin A was significantly affected by storage and the type of techniques used to make rice premix. Losses for iron and zinc were typically <10% for any type of rice premix. After 12 months at mild conditions (25 °C and humidity of 60%), losses for vitamin A ranged from 20% for cold extrusion, 30% for hot extruded rice 77% for coated rice premix. At higher temperatures and humidity, losses of vitamin A were 40%–50% for extruded premix and 93% for coated premix after 6 months. We conclude that storage does lead to a major loss of vitamin A and question whether rice is a suitable food vehicle to fortify with vitamin A. For Cambodia, fortification of rice with iron and zinc could be an effective strategy to improve the micronutrient status of the population if no other food vehicles are available.

An Assessment of the Potential Impact of Fortification of Staples and Condiments on Micronutrient Intake of Young Children and Women of Reproductive Age in Bangladesh

Bangladesh has experienced rapid economic growth and achieved major health improvements in the past decade, but malnutrition rates remain high. A nationally representative study conducted in 2011 assessed the dietary habits of 841 children 24-59 months old; 1428 children 6-14 years old; and 1412 non-pregnant, non-lactating women. The study's objective was to assess dietary intakes of key micronutrients and the consumption pattern of potentially fortifiable foods, and then to model the potential impact of fortification of key staple foods. The current intakes of several micronutrients, namely, iron, zinc, folate, vitamin A and vitamin B12, were found to be insufficient to meet the needs of Bangladesh's children and women. The fortification of rice with iron and zinc and edible oil with vitamin A has the potential to fill a significant part of the nutrient gap, as these are consumed widely and in significant amounts. Wheat flour and sugar are not as promising food vehicles in the Bangladeshi context, as they were consumed by a smaller portion of the population and in smaller amounts. In conclusion, fortification of rice and oil is recommended to address the large gap in micronutrient intakes.

A Blinded, Cluster-Randomized, Placebo-Controlled School FeedingTrial in Burundi Using Rice Fortified With Iron, Zinc, Thiamine, and Folic Acid

BACKGROUND

Iron-deficiency anemia is a major public health problem among school-aged children in sub-Saharan Africa.

OBJECTIVE

To evaluate the effectiveness of micronutrient-fortified rice to increase hemoglobin (Hb) concentration and reduce the prevalence of anemia among schoolchildren.

METHODS

Nine hundred four schoolchildren participated in this cluster-randomized trial during a 7-month intervention period. The study was conducted in 12 primary schools in rural Burundi. Hemoglobin, socioeconomic status, febrile illness, and dietary diversity were measured at baseline and follow-up. The changes in Hb concentration and anemia status were analyzed using linear and logistic mixed models, respectively. The micronutrient formulation contained an iron-to-zinc molar ratio of approximately 2.2.

RESULTS

There was no significant difference in Hb concentration between the intervention and control groups (β = .09 g/dL; 95% confidence interval: -0.21 to 0.38) following the 7-month intervention. Nearly half the children reported having a fever within 2 weeks prior to baseline or follow-up. Children with febrile illness preceding follow-up were less than half as likely to show improvement in anemia status (odds ratio = 0.47, P < .001), with an average 0.56 g/dL smaller improvement in Hb at follow-up (P < .001).

CONCLUSION

The high prevalence of fever and low iron-to-zinc molar ratio of the Ultra Rice formulation may have contributed to the lack of improvement in Hb. Alternatively, the detected anemia may not have been due to nutrient deficiencies. Anemia interventions in Burundi should implement multiple strategies to eliminate both iron deficiency and infectious causes of anemia.

Prospects of breeding high-quality rice using post-genomic tools

The holistic understanding derived from integrating grain quality and sensory research outcomes in breeding high-quality rice in the light of post-genomics resources has been synthesized. Acceptance of new rice genotypes by producers and consumers hinges not only on their potential for higher yield but recent emphasis has also been on premium-value genotypes that have the ability to satisfy consumer preferences for grain quality. This review article provides insights into how to link grain quality attributes and sensory perception to support breeding superior rice varieties. Recent advances in quality profiling and omics technologies have provided efficient approaches to identify the key genes and biochemical markers involved in rice quality traits. Emphasis has been given to the upcoming area of holistic understanding of grain quality and attributes derived from sensory evaluation to leverage integrative gene discovery strategies that enable breeding programs to efficiently tap the huge genetic diversity in rice for novel genes that enhance rice food quality.

Iron fortification adversely affects the gut microbiome, increases pathogen abundance and induces intestinal inflammation in Kenyan infants

BACKGROUND

In-home iron fortification for infants in developing countries is recommended for control of anaemia, but low absorption typically results in >80% of the iron passing into the colon. Iron is essential for growth and virulence of many pathogenic enterobacteria. We determined the effect of high and low dose in-home iron fortification on the infant gut microbiome and intestinal inflammation.

METHODS

We performed two double-blind randomised controlled trials in 6-month-old Kenyan infants (n=115) consuming home-fortified maize porridge daily for 4 months. In the first, infants received a micronutrient powder (MNP) containing 2.5 mg iron as NaFeEDTA or the MNP without iron. In the second, they received a different MNP containing 12.5 mg iron as ferrous fumarate or the MNP without the iron. The primary outcome was gut microbiome composition analysed by 16S pyrosequencing and targeted real-time PCR (qPCR). Secondary outcomes included faecal calprotectin (marker of intestinal inflammation) and incidence of diarrhoea. We analysed the trials separately and combined.

RESULTS

At baseline, 63% of the total microbial 16S rRNA could be assigned to Bifidobacteriaceae but there were high prevalences of pathogens, including Salmonella Clostridium difficile, Clostridium perfringens, and pathogenic Escherichia coli. Using pyrosequencing, +FeMNPs increased enterobacteria, particularly Escherichia/Shigella (p=0.048), the enterobacteria/bifidobacteria ratio (p=0.020), and Clostridium (p=0.030). Most of these effects were confirmed using qPCR; for example, +FeMNPs increased pathogenic E. coli strains (p=0.029). +FeMNPs also increased faecal calprotectin (p=0.002). During the trial, 27.3% of infants in +12.5 mgFeMNP required treatment for diarrhoea versus 8.3% in -12.5 mgFeMNP (p=0.092). There were no study-related serious adverse events in either group.

CONCLUSIONS

In this setting, provision of iron-containing MNPs to weaning infants adversely affects the gut microbiome, increasing pathogen abundance and causing intestinal inflammation.

TRIAL REGISTRATION NUMBER

NCT01111864.

Organoleptic qualities and acceptability of fortified rice in two Southeast Asian countries

Fortified rice has the potential to improve the micronutrients status of vulnerable populations. However, fortified rice has to have acceptable organoleptic--the sensory properties of a particular food--qualities. Few data exist on the acceptability of fortified rice in Asia. To assess the acceptability of two types of fortified rice (cold and hot extruded) in Vietnam and Cambodia, triangle tests were conducted in Vietnam (53 women) and Cambodia (258 adults), testing fortified rice against conventional rice, with participants being asked to score the organoleptic qualities. In addition, Cambodian schoolchildren (n = 1700) were given conventional rice and two types of fortified rice for two week periods as part of a World Food Program school meal program, with intake monitored. Fortified rice differed significantly in organoleptic qualities from conventional rice, with most subjects correctly identifying fortified rice (P < 0.001). However, fortified rice was found to be highly acceptable in both countries. In Cambodia, schoolchildren consuming fortified rice had higher intakes than when consuming conventional rice (176 g/child/day and 168 g/child/day, respectively; P < 0.05). This study shows that fortified rice is acceptable in two countries in Southeast Asia. However, specific information is needed to explain the organoleptic qualities of fortified rice as perceived by end-users.

Fortification of rice: technologies and nutrients

This article provides a comprehensive review of the currently available technologies for vitamin and mineral rice fortification. It covers currently used technologies, such as coating, dusting, and the various extrusion technologies, with the main focus being on cold, warm, and hot extrusion technologies, including process flow, required facilities, and sizes of operation. The advantages and disadvantages of the various processing methods are covered, including a discussion on micronutrients with respect to their technical feasibility during processing, storage, washing, and various cooking methods and their physiological importance. The microstructure of fortified rice kernels and their properties, such as visual appearance, sensory perception, and the impact of different micronutrient formulations, are discussed. Finally, the article covers recommendations for quality control and provides a summary of clinical trials.

Childhood malnutrition and parasitic helminth interactions

BACKGROUND

There is evidence to support that nutritional deficiency can reduce the body's immune function, thereby decreasing resistance to disease and increasing susceptibility to intestinal parasites.

METHODS

A cross-sectional survey was carried out on 693 school-aged children from 5 schistosomiasis-endemic villages in Northern Samar, the Philippines. Data on dietary intake, nutritional status, and intestinal parasitic infection were collected.

RESULTS

The prevalence of stunting, thinness, and wasting was 49.2%, 27.8%, and 59.7% of all children. The proportion of children infected with Schistosoma japonicum (15.6%, P = .03) and hookworm (22.0%, P = .05) were significantly lower among children who met the recommended energy and nutrient intake (RENI) for total calories. The percentage of children infected with Trichuris trichiura was highest among children who did not meet the RENI for energy (74.1%, P = .04), iron (73.4%, P = .01), thiamine (74.0%, P = .00), and riboflavin (73.3%, P = .01). Susceptibility to having 1 or more parasitic infections was significantly associated with poor intake of energy (P = .04), thiamine (P = .02), and riboflavin (P = .01).The proportion of stunted children was significantly higher among children who did not meet the RENI for energy (68.9%, P = .002), protein (54.0%, P = .004), or niacin (30.8%, P = .02) and for those infected with hookworm (31.8%, P = .0002). After adjusting for potential confounders, protein intake less than the RENI (odds ratio [OR], 1.48; 95% confidence interval [CI], 1.03-2.14), and hookworm infection (OR, 1.77; 95% CI, 1.22-2.55) were the major predictors of stunting.

CONCLUSIONS

The results support the hypothesis that poor nutrient intake may increase susceptibility to parasitic diseases and together they negatively affect childhood nutritional status.

Triple-fortified rice containing vitamin A reduced marginal vitamin A deficiency and increased vitamin A liver stores in school-aged Thai children

Vitamin A (VA)-fortified rice is a potential intervention strategy to prevent VA deficiency in at-risk populations. Hot-extruded, triple-fortified rice grains with added VA, zinc, and iron were produced by hot extrusion technology and their ability to improve VA status was tested in Thai schoolchildren. The fortification levels were 10 mg of iron, 9 mg of zinc, and 1.05 mg of VA/g extruded rice. A paired stable isotope dilution technique with labeled ¹³C₂-retinyl acetate (¹³C-RID) was used to quantify VA pool size at the beginning and end of the feeding period. Fifty healthy schoolchildren with a serum retinol (SR) concentration of >0.7 μmol/L were randomly assigned to 2 groups to receive either triple-fortified rice (n = 25) or natural rice (n = 25) for 2 mo as part of the daily school meal. The fortified grains, mixed 1:50 with regular rice, were estimated to provide an extra 890 μg of VA/d, 5 d/wk. ¹³C₂-retinyl acetate (1.0 μmol) was administered orally to each child before and at the end of the feeding period to estimate total body reserves (TBRs) of VA, which increased significantly (P < 0.05) in the intervention group from 153 ± 66 μmol retinol at baseline to 269 ± 148 μmol retinol after 2 mo of feeding. There was no change in the TBRs of VA in the control group (108 ± 67 vs. 124 ± 89 μmol retinol) (P = 0.22). Serum retinol remained unchanged in both groups. We conclude that VA-fortified, hot-extruded rice is an efficacious vehicle to provide additional VA to at-risk populations, and that the efficacy of VA-fortified foods can be usefully monitored by the ¹³C-RID measurement of TBRs of VA but not by changes in SR concentration.