Vegetable oil of poor quality is limiting the success of fortification with vitamin A in Egypt

Stabilisation of vitamin A by wheat bran is affected by wheat bran antioxidants, bound lipids and endogenous lipase activity

Food fortification is an efficient strategy to combat vitamin A deficiency. However, the stability of vitamin A during storage is low. Cereal bran can be used as a natural and affordable stabilising agent, but the mechanism behind this stabilisation remains unclear. To unravel this mechanism, vitamin A stabilisation was studied during an accelerated storage experiment (60 °C, 70% relative humidity) using a set of 30 in-house modified wheat bran samples. The characteristics of these samples were linked to vitamin A stabilisation during storage using forward regression modelling. While all wheat bran samples could stabilise vitamin A to a significant extent, the stabilising effect was more pronounced for samples with a high antioxidant capacity, high bound lipid content and low lipase activity. The main effect of lipase activity was more than thrice as large as the main effects of antioxidant capacity and bound lipid content. These results suggest that wheat bran antioxidants and bound lipids protect vitamin A from degradation during storage, while endogenous lipase activity counteracts the stabilising effect. Based on these findings, modified wheat bran mixed with vitamin A can be a cost-effective and healthy aid in food fortification by providing high vitamin A stability.

Vitamin A Fortification Quality Is High for Packaged and Branded Edible Oil but Low for Oil Sold in Unbranded, Loose Form: Findings from a Market Assessment in Bangladesh

Although mandatory fortification of oil with vitamin A is efficacious, its effectiveness can be compromised by suboptimal compliance to standards. In this study, we assessed (1) the availability of oil brands across the eight divisions of Bangladesh, (2) fortification quality (the extent to which vitamin A content is aligned with fortification standards) of oil brands and producers and (3) the market volume represented by available edible oil types. We visited different retail outlets in rural and urban market hubs to ascertain available oil brands and bulk oil types and collected samples. We used high-performance liquid chromatography to quantify average vitamin A content and compared them to the national oil fortification standards. Among the 66 packaged brands analyzed, 26 (39%) were not fortified, and 40 (61%) were fortified, with 28 (42%) fortified above the standard vitamin A minimum. Among the 41 bulk oil type composites analyzed, 24 (59%) were not fortified, and 17 (41%) were fortified, with 14 (34%) fortified below and 3 (7%) fortified above the standard minimum. Vitamin A fortification is high for packaged and branded edible oil but low for oil sold in unbranded, loose form. As bulk oil makes up a large proportion of the oil market volume, this means the majority of the oil volume available to the population is either not (25%) or fortified below the standard requirement (39%). Regulatory inspections of producers selling bulk oil should be prioritized to support and incentivize the industry to make all oil traceable and fortified to standard.

The Effect of Red Palm Oil on Vitamin A Deficiency: A Meta-Analysis of Randomized Controlled Trials

Red palm oil (RPO) has been investigated for preventing or alleviating vitamin A deficiency (VAD). Previous data has offered inconclusive and inconsistent results about the effects of RPO in patients with VAD. Our objective was to undertake a meta-analysis to assess the effects of RPO in preventing VAD in the population. After conducting a comprehensive literature search, nine randomized controlled trials (RCTs) were included. Overall, when trial results were pooled, the results indicated that RPO reduced the risk of VAD (relative risk (RR) (95% confidence interval (CI)) = 0.55 (0.37, 0.82), p = 0.003), increasedserum retinol levels in both children (p < 0.00001) and adults (p = 0.002), and increased β-carotene levels (p = 0.01). However, RPO supplementation did not have a significant overall effect on serum α-carotene levels (p = 0.06), body weight (p = 0.45), and haemoglobin levels (p = 0.72). The results also showed that low level of PRO intake (≤8 g RPO) could increase serum retinol concentrations whereas PRO intake above 8 g did not lead to further increase of serum retinol concentrations. This meta-analysis demonstrated that RPO might be effective for preventing or alleviating VAD.

Evaluation of Palm Oil as a Suitable Vegetable Oil for Vitamin A Fortification Programs

Fortification programs are considered to be an effective strategy to mitigate vitamin A deficiency in populations at risk. Fortified vegetable oils rich in polyunsaturated fatty acids were shown to be prone to oxidation, leading to limited vitamin A stability. Thus, it was hypothesized that fortified oils consisting of mainly saturated fatty acids might enhance the stability of vitamin A. Mildly (peroxide value: 1.0 meq O₂/kg) and highly (peroxide value: 7.5 meq O₂/kg) oxidized palm oil was stored, after fortification with 60 International Units/g retinyl palmitate, in 0.5 L transparent polyethylene terephthalate bottles under cold fluorescent lighting (12 h/day) at 32 °C for 57 days. An increase of the peroxide value by 15 meq O₂/kg, which was also reflected by a decrease of α-tocopherol congener by 15%–18%, was determined independent of the initial rancidity. The oxidative deterioration of the highly oxidized palm oil during storage was correlated with a significant 46% decline of the vitamin A content. However, household storage of mildly oxidized palm oil for two months did not induce any losses of vitamin A. Thus, mildly oxidized palm oil may be recommended for vitamin A fortification programs, when other sources of essential fatty acids are available.

Vitamin A degradation in triglycerides varying by their saturation levels

Vitamin A deficiency has a widespread occurrence globally and is considered as one of the world's most serious health risk factors. Potential solutions to address this deficiency include dietary diversification or supplementation, but food fortification is generally accepted as the most cost-effective solution. The main issue with food fortification of this vitamin is related to its high instability in food matrices. Dilution of vitamin A in triglycerides is a natural and appropriate way to stabilize this compound. We show here that vitamin A palmitate stability increases with increasing concentration of triglycerides. Moreover, we found that vitamin A palmitate displays improved stability in more saturated oils. Using various temperatures, and Arrhenius plots of experiments performed at storage temperatures between 30°C and 60°C for oils varying by their saturation and crystallinity, we demonstrate that crystallization is not responsible for this phenomenon. Additionally, we show by centrifugation that vitamin A is preferably solubilized in the liquid phase compared to the crystalline phase, explaining that triglyceride crystallization does not stabilize vitamin A palmitate. It is proposed that unsaturated fats generate more oxidation products such as radicals and peroxides, leading to a quicker degradation of vitamin A.

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.

Influence of light exposure and oxidative status on the stability of vitamins A and D₃ during the storage of fortified soybean oil

Food fortification is implemented to address vitamins A and D deficiencies in numerous countries. The stability of vitamins A and D3 was assessed during a two-month period reproducing the usual oil storage conditions before sale to consumers. Soybean oils with different oxidative status and vitamin E contents were stored in the dark, semi-dark, or exposed to natural light. Lipid peroxidation took place after 3 weeks of storage in dark conditions. After 2 months, the vitamin A and D3 losses reached 60-68% and 61-68%, respectively, for oils exposed to natural light, and 32-39% and 24-44% in semi-dark conditions. The determining factors of vitamin A and D3 losses were (in decreasing order) the storage time, the exposure to light and the oxidative status of the oil, whereas vitamin E content had a protective role. Improving these parameters is thus essential to make vitamins A and D fortification in oils more efficient.

Vitamin A-fortified cooking oil reduces vitamin A deficiency in infants, young children and women: results from a programme evaluation in Indonesia

OBJECTIVE

To assess oil consumption, vitamin A intake and retinol status before and a year after the fortification of unbranded palm oil with retinyl palmitate.

DESIGN

Pre-post evaluation between two surveys.

SETTING

Twenty-four villages in West Java.

SUBJECTS

Poor households were randomly sampled. Serum retinol (adjusted for subclinical infection) was analysed in cross-sectional samples of lactating mothers (baseline n 324/endline n 349), their infants aged 6-11 months (n 318/n 335) and children aged 12-59 months (n 469/477), and cohorts of children aged 5-9 years (n 186) and women aged 15-29 years (n 171), alongside food and oil consumption from dietary recall.

RESULTS

Fortified oil improved vitamin A intakes, contributing on average 26 %, 40 %, 38 %, 29 % and 35 % of the daily Recommended Nutrient Intake for children aged 12-23 months, 24-59 months, 5-9 years, lactating and non-lactating women, respectively. Serum retinol was 2-19 % higher at endline than baseline (P<0·001 in infants aged 6-11 months, children aged 5-9 years, lactating and non-lactating women; non-significant in children aged 12-23 months; P=0·057 in children aged 24-59 months). Retinol in breast milk averaged 20·5 μg/dl at baseline and 32·5 μg/dl at endline (P<0·01). Deficiency prevalence (serum retinol <20 μg/dl) was 6·5-18 % across groups at baseline, and 0·6-6 % at endline (P≤0·011). In multivariate regressions adjusting for socio-economic differences, vitamin A intake from fortified oil predicted improved retinol status for children aged 6-59 months (P=0·003) and 5-9 years (P=0·03).

CONCLUSIONS

Although this evaluation without a comparison group cannot prove causality, retinyl contents in oil, Recommended Nutrient Intake contributions and relationships between vitamin intake and serum retinol provide strong plausibility of oil fortification impacting vitamin A status in Indonesian women and children.

Quality of vegetable oil prior to fortification is an important criteria to achieve a health impact

Unbranded palm cooking oil has been fortified for several years and can be found in the market with different oxidation levels. This study aimed to investigate the stability and shelf life of unbranded, bulk, vitamin A-fortified palm oils with the most commonly observed oxidation levels in Indonesia. Three types of cooking oils were tested: (i) cooking oil with a peroxide value (PV) below 2 mEq O₂/kg (PO1); (ii) cooking oil with a PV around 4 mEq O₂/kg (PO2); and (iii) cooking oil with a PV around 9 mEq O₂/kg (PO3). The oil shelf life was determined by using accelerated shelf life testing (ASLT), where the product was stored at 60, 75 and 90 °C, and then PV, free fatty acid and vitamin A concentration in the oil samples were measured. The results showed that PO1 had a shelf life of between 2–3 months, while PO2’s shelf life was a few weeks and PO3’s only a few days. Even given those varying shelf lives, the vitamin A loss in the oils was still acceptable, at around 10%. However, the short shelf life of highly oxidized cooking oil, such as PO3, might negatively impact health, due to the potential increase of free radicals of the lipid peroxidation in the oil. Based on the results, the Indonesian government should prohibit the sale of highly-oxidized cooking oil. In addition, government authorities should promote and endorse the fortification of only cooking oil with low peroxide levels to ensure that fortification is not associated with any health issues associated with high oxidation levels of the cooking oil.

Simulations based on representative 24-h recall data predict region-specific differences in adequacy of vitamin A intake among Cameroonian women and young children following large-scale fortification of vegetable oil and other potential food vehicles

BACKGROUND

The WHO recommends assessing food and nutrient intakes to design food-fortification programs, but nationally representative dietary data are seldom available in low-income countries.

OBJECTIVE

Prior to initiation of food fortification in Cameroon, we measured intake of vitamin A (VA) and fortifiable foods (vegetable oil, sugar, wheat flour, and bouillon cube) to simulate the effects of fortification with different foods and VA amounts on prevalence of inadequate and excessive VA intake.

METHODS

Twenty-four-hour recalls were conducted among 912 women and 883 children (with duplicates in a subset) in a nationally representative cluster survey stratified by region (North, South, Yaoundé/Douala). Usual intake distributions were estimated by the National Cancer Institute method.

RESULTS

Nationally, 53% of women had a usual intake of <500 μg retinol activity equivalents/d, and 59% of nonbreastfeeding children had an intake of <210 μg retinol activity equivalents/d, although VA intake varied by region. The current fortification program (12 mg/kg VA in oil) would decrease the prevalence of inadequate intakes to 35% among both women and children, without increasing the proportion with retinol intakes >3000 μg/d among women or >600 μg/d among children. However, inadequate VA intake would remain >50% in the North, where VA deficiency was most common. Increasing VA in oil or fortifying a second food (sugar, wheat flour, or bouillon cube) would further decrease the prevalence of inadequate intakes, but, depending on the food vehicle and region, would also increase the prevalence of retinol intakes above the tolerable upper intake level, mainly among children.

CONCLUSIONS

The current food-fortification program can be expected to improve dietary VA adequacy without increasing the risk of excessive intake among women and children in Cameroon. Modifications to the program must balance the potential to further increase VA intake with the risk of excessive intake among children.

Vitamin A is rapidly degraded in retinyl palmitate-fortified soybean oil stored under household conditions

Oil fortification with retinyl palmitate is intended to lower the prevalence of vitamin A deficiency in populations at risk. Although the stability of vitamin A in vegetable oil has been shown to depend on environmental factors, very little information is known about the stability of vitamin A in preoxidized vegetable oils. The present study investigated the stability of retinyl palmitate in mildly oxidized (peroxide value < 2 mequiv O2/kg) and highly oxidized (peroxide value > 10 mequiv O2/kg) soybean oil stored under domestic and retail conditions. Soybean oil was filled in transparent bottles, which were exposed to cold fluorescent light at 22 or 32 °C for 56 days. Periodic oil sampling increased the headspace, thereby mimicking consumer handling. Loss of retinyl palmitate in soybean oil by a maximum of 84.8 ± 5.76% was accompanied by a decrease of vitamin E by 53.3 ± 0.87% and by an increase of the peroxide value from 1.20 ± 0.004 to 24.3 ± 0.02 mequiv O2/kg. Fortification of highly oxidized oil with 31.6 IU/g retinyl palmitate led to a doubling of the average decrease of retinol per day compared to fortification of mildly oxidized oil. In conclusion, oil fortification programs need to consider the oxidative status of the oil used for retinyl palmitate fortification.

The global, centralized approach of the GAIN Premix Facility has made oil fortification in Indonesia more affordable

BACKGROUND

Access to high-grade micronutrients is a recurring challenge that often threatens the long-term sustainability of food fortification programs.

OBJECTIVE

To assess the efficiency of the Global Alliance for Improved Nutrition (GAIN) Premix Facility in procuring quality, affordable vitamin A for fortification of edible oil in Indonesia.

METHODS

A global approach to procurement of standard items was used by combining volumes across various demand streams in order to reduce the total cost of acquisition through economies of scale. The GAIN Premix Facility undertook a detailed analysis of vitamin A requirements across its existing customer base, which served as a basis for developing a reliable demand forecast. A consolidated, competitive tender was launched that resulted in the setting up of a long-term commercial agreement with the selected supplier to lock in the most competitive price for a given period of time.

RESULTS

The direct benefit to oil manufacturers of fortifying with vitamin A is that the cost of fortification went down significantly compared with prices they would have been offered had they ordered vitamin A individually. In Indonesia, this consolidated procurement approach has allowed a 14.5% decrease in the unit price of vitamin A.

CONCLUSIONS

The GAIN Premix Facility demonstrated its effectiveness in acting as a global procurement platform by aggregating demand across different customers and leveraging improved prices through increased volumes. Building on the success of this effort, the GAIN Premix Facility is replicating this global approach for procurement of other standard items being procured across fortification programs worldwide.

Fish sauce, soy sauce, and vegetable oil fortification in Cambodia: where do we stand to date?

BACKGROUND

The prevalence of micronutrient deficiencies in Cambodia is among the highest in Southeast Asia. Fortification of staple foods and condiments is considered to be one of the most cost-effective strategies for addressing micronutrient deficiencies at the population level. The Government of Cambodia has recognized the importance of food fortification as one strategy for improving the nutrition security of its population.

OBJECTIVE

This paper describes efforts under way in Cambodia for the fortification of fish sauce, soy sauce, and vegetable oil.

METHODS

Data were compiled from a stability test of Cambodian fish sauces fortified with sodium iron ethylenediaminetetraacetate (NaFeEDTA); analysis of fortified vegetable oils in the Cambodian market; a Knowledge, Attitudes, and Practices (KAP) study of fortified products; and food fortification program monitoring documents.

RESULTS

At different levels of fortification of fish sauce with NaFeEDTA, sedimentation and precipitation were observed. This was taken into consideration in the government-issued standards for the fortification of fish sauce. All major brands of vegetable oil found in markets at the village and provincial levels are imported, and most are nonfortified.

CONCLUSIONS

Fish sauce, soy sauce, and vegetable oil are widely consumed throughout Cambodia and are readily available in provincial and village markets. Together with an effective regulatory monitoring system, the government can guarantee that these commodities, whether locally produced or imported, are adequately fortified. A communications campaign would be worthwhile, once fortified commodities are available, as the KAP study found that Cambodians had a positive perception of fortified sauces.

A comparison of retinyl palmitate and red palm oil β-carotene as strategies to address Vitamin A deficiency

Vitamin A deficiency continues to be an international public health problem with several important health consequences including blindness and overall increased rates of morbidity and mortality. To address this widespread issue, a series of strategies have been put into place from dietary diversification to supplementation and fortification programs. Retinyl palmitate has been used successfully for decades as a supplement as well as a way to fortify numerous foods, including vegetable oil, rice, monosodium glutamate, cereal flours and sugar. Recently, there has been rising interest in using a natural source of carotenoids, β-carotene from red palm oil (RPO), for fortification. Although RPO interventions have also been shown to effectively prevent Vitamin A deficiency, there are numerous challenges in using beta-carotene from RPO as a fortification technique. β-Carotene can induce significant changes in appearance and taste of the fortified product. Moreover, costs of fortifying with beta-carotene are higher than with retinyl palmitate. Therefore, RPO should only be used as a source of Vitamin A if it is produced and used in its crude form and regularly consumed without frying. Furthermore, refined RPO should be fortified with retinyl palmitate, not β-carotene, to ensure that there is adequate Vitamin A content.

The Growing Importance of Staple Foods and Condiments Used as Ingredients in the Food Industry and Implications for Large-Scale Food Fortification Programs in Southeast Asia

Background

Food fortification is a viable strategy to improve the nutritional status of populations. In South-east Asia, recent growth and consolidation of the food industry provides an opportunity to explore whether certain widely consumed processed foods could contribute to micronutrient status if they are made with adequately fortified staples and condiments.

Objective

To estimate the potential contribution certain processed foods can make to micronutrient intake in Southeast Asia if they are made with fortified staples and condiments; e.g., via the inclusion of iodized salt in various processed foods in the Philippines, fortified wheat flour in instant noodles in Indonesia, and fortified vegetable oil in biscuits in Vietnam.

Methods

For Indonesia, the Philippines, and Vietnam, a review of consumption trends, relevant policies, and industry practices was conducted using publicly available sources, food industry market data and research reports, and oral communication. These informed the estimates of the proportion of the Recommended Nutrient Intake (RNI) that could be delivered via select processed foods.

Results

In the Philippines, Indonesia, and Vietnam, the processed food industry is not always required to use fortified staples and condiments. In the Philippines, dried salted fish with iodized salt would provide 64% to 85% of the iodine RNI for women of reproductive age and 107% to 141% of the iodine RNI for children 1 to 6 years of age. In Indonesia, a 75-g pack of instant noodles (a highly consumed product) with fortified wheat flour would provide 45% to 51% of the iron RNI for children 4 to 6 years of age and 10% to 11% of the iron RNI for women of reproductive age. In Vietnam, biscuits containing vegetable oil are increasingly popular. One 35-g biscuit serving with fortified vegetable oil would provide 13% to 18% of the vitamin A RNI for children 4 to 6 years of age and 12% to 17% of the vitamin A RNI for women of reproductive age.

Conclusions

Ensuring that fortified staples and condiments such as flour, salt, and vegetable oil are used in widely consumed processed foods would ensure that these foods contribute to improvement in micronutrient intake among populations in Southeast Asia, particularly as the consumption of these foods is increasing. Policymakers and nutrition program managers should consider the contribution to nutritional intake that fortified staples and condiments can provide through processed foods, in addition to being used for cooking in the home, and ensure that the food industry is required to use these fortified staples and condiments rather than nonfortified foods.

Fortifying baladi bread in Egypt: reaching more than 50 million people through the subsidy program

BACKGROUND

Micronutrient deficiencies, especially iron-deficiency anemia, are a public health problem in Egypt, where anemia rates almost doubled in the years from 2000 to 2005. In 2008, the Government of Egypt began implementation of a 5-year national program to fortify with iron and folic acid the wheat flour used in baking subsidized baladi bread, the staple food consumed by a majority of low- income groups.

OBJECTIVE

To project the achievements of this national Wheat Flour Fortification Program.

METHODS

This paper describes the program, estimates the production of fortified flour and consumption of fortified bread, and identifies program challenges and sustainability issues.

RESULTS

Through the national Wheat Flour Fortification Program, ferrous sulfate and folic acid are now added to all wheat flour produced under the national Food Subsidy Program. Up to 50 million Egyptians nationwide are now consuming quality-assured fortified baladi bread on a daily basis. In 2011, 6.5 million MT of fortified wheat flour was produced by 143 participating public- and private-sector mills. Political changes in Egypt in 2011 did not seem to affect the program; the new leadership in the Ministry of Supply and Internal Trade remains committed to fortification of wheat flour.

CONCLUSIONS

The daily intake of approximately 12 mg of iron and 600 microg of folic acid through the consumption of baladi bread suggests that the impact of the program on the prevention and reduction of iron and folate deficiencies among the Egyptian population could be significant; the results of an end-line survey are pending.