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Fortification to Combat Micronutrient Deficiencies

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A special issue of Nutrients (ISSN 2072-6643).

Deadline for manuscript submissions: closed (30 June 2016) | Viewed by 92253

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Dr. Karen Charlton

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School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, 2522, Australia
Interests: nutritional epidemiology; chronic disease; nutrition, health and ageing; food and nutrition monitoring; food security; salt reduction; micronutrient status of populations; dietary methodology
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Prof. Dr. Nelia Steyn

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Division Human Nutrition, Department of Human Biology, University of Cape Town, P/Bag X3, Observatory, Cape Town 7925, South Africa
Interests: dietary methodology; non-communicable diseases; type 2 diabetes; obesity and the double burden of malnutrition
Special Issues, Collections and Topics in MDPI journals

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Dear Colleagues,

Micronutrient deficiencies affect about two billion people worldwide, and account for 11% of the global public health burden. Fortification of foods with micronutrients is considered a simple, scalable and inexpensive solution to tackle this issue. Worldwide, the three most common forms of micronutrient malnutrition are iron, vitamin A and iodine deficiency. Together, these affect at least one third of the world’s population, the majority of whom are in developing countries. Of the three, iron deficiency is the most prevalent.

Micronutrient malnutrition is a concern not just because of the large numbers of people that are affected, but also because micronutrient deficiencies contribute to high rates of morbidity and mortality. According to WHO mortality data, around 0.8 million deaths can be attributed to iron deficiency each year, and a similar number to vitamin A deficiency. Micronutrient deficiency not only impacts on the health of populations, but also affects economic development and productivity of countries. Iodine deficiency, for example, reduces developmental potential in children due to loss of IQ points and results in cognitive deficits.

Food fortification is considered an important tool to make progress towards the achievement of some of the United Nations’ Sustainable Development Goals (SDGs). Through signing up to the SDGs declaration, governments are committed to reducing poverty, hunger and malnutrition. Fortification offers an immediate solution to the latter.

Fortification efforts need to be informed by good quality scientific evidence. In-country policies, standards and regulations need to be enforced, and accompanied by transparency in delivery of programmes. Importantly, monitoring and surveillance of fortification strategies are essential to ensure effectiveness and reach, but without the risk of excess in sectors of the population. Advocacy efforts are often needed to influence food regulatory bodies and policy makers to keep prevention of malnutrition on the health agenda.

This Special Issue titled “Fortification to combat micronutrient deficiencies” will address these integral aspects and provide examples from different countries of fortification strategies that have been adopted.

Dr. Karen Charlton
Dr. Nelia Steyn
Guest Editors

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Keywords

fortification
Evaluation
Micronutrients
fortificants

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784 KiB

Open AccessArticle

Dietary Iodine Intake of the Australian Population after Introduction of a Mandatory Iodine Fortification Programme

by Karen Charlton, Yasmine Probst and Gabriella Kiene

Nutrients 2016, 8(11), 701; https://doi.org/10.3390/nu8110701 - 4 Nov 2016

Cited by 30 | Viewed by 7522

Abstract

To address mild iodine deficiency in Australia, a mandatory fortification program of iodised salt in bread was implemented in 2009. This study aimed to determine factors associated with achieving an adequate dietary iodine intake in the Australian population post-fortification, and to assess whether bread consumption patterns affect iodine intake in high-risk groups. Using nationally representative data of repeated 24-h dietary recalls from the 2011–2012 Australian National Nutrition and Physical Activity Survey, dietary iodine intakes and food group contributions were compared by age, socioeconomic status (SES), and geographical remoteness (N = 7735). The association between fortified bread intake and adequacy of iodine intake (meeting age and sex-specific Estimated Average Requirements) was investigated using logistic regression models in women of childbearing age 14–50 years (n = 3496) and children aged 2–18 years (n = 1772). The effect of SES on bread consumption was further investigated in a sub group of children aged 5–9 years (n = 488). Main sources of iodine intake at the time of the survey were cereal and cereal products, followed by milk products and dishes. Differences in iodine intake and dietary iodine habits according to age, SES and location were found (p < 0.001) for women of child-bearing age. Fortified bread consumption at ≥100 g/day was associated with five times greater odds of achieving an adequate iodine intake (OR 5.0, 95% CI 4.96–5.13; p < 0.001) compared to lower bread consumption in women and 12 times in children (OR 12.34, 95% CI 1.71–89.26; p < 0.001). Disparities in dietary iodine intake exist within sectors of the Australian population, even after mandatory fortification of a staple food. On-going monitoring and surveillance of iodine status is required. Full article

(This article belongs to the Special Issue Fortification to Combat Micronutrient Deficiencies)

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579 KiB

Open AccessArticle

Evidence Synthesis and Translation for Nutrition Interventions to Combat Micronutrient Deficiencies with Particular Focus on Food Fortification

by Mark Lawrence, Kate Wingrove, Celeste Naude and Solange Durao

Nutrients 2016, 8(9), 555; https://doi.org/10.3390/nu8090555 - 8 Sep 2016

Cited by 10 | Viewed by 7745

Abstract

Over two billion people suffer from micronutrient deficiencies. Food fortification is a prominent nutrition intervention to combat such deficiencies; however, its effectiveness, risks, and ethical implications vary depending on the contexts associated with the deficiency it is addressing and the circumstances with its implementation. The aim of this research was to analyse the profile of nutrition interventions for combating micronutrient deficiency with particular focus on food fortification reported in existing systematic reviews (SRs), guidelines and policy statements, and implementation actions for nutrition. A review of secondary data available from online databases of SRs, guidelines and policy statements, and implementation actions, categorised as either “nutrition-specific interventions” (NSpI) or “nutrition-sensitive interventions” (NSeI), was conducted. Currently, there is evidence available for a diversity of food fortification topics, and there has been much translation into action. Indeed, food fortification and micronutrient supplementation interventions and NSpI more broadly dominate the profile of interventions for which there were SRs, guidelines, and policy statements available. The findings demonstrate that, although there is a rational linear relationship between evidence synthesis and translation in formulating policy and actions to combat micronutrient deficiencies, the various nutrition interventions available to help combat micronutrient deficiencies are not equally represented in the evidence synthesis and translation processes. Effective and safe policies and actions to combat micronutrient deficiencies require decisions to be informed from a body of evidence that consists of evidence from a variety of interventions. Into the future, investment in making available a higher number of SRs, guidelines and policy statements, and actions of NSeI is indicated. Full article

(This article belongs to the Special Issue Fortification to Combat Micronutrient Deficiencies)

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198 KiB

Open AccessCommunication

Iodisation of Salt in Slovenia: Increased Availability of Non-Iodised Salt in the Food Supply

by Katja Žmitek and Igor Pravst

Nutrients 2016, 8(7), 434; https://doi.org/10.3390/nu8070434 - 16 Jul 2016

Cited by 9 | Viewed by 6691

Abstract

Salt iodisation is considered a key public health measure for assuring adequate iodine intake in iodine-deficient countries. In Slovenia, the iodisation of all salt was made mandatory in 1953. A considerable regulatory change came in 2003 with the mandatory iodisation of rock and evaporated salt only. In addition, joining the European Union’s free single market in 2004 enabled the import of non-iodised salt. The objective of this study was to investigate the extent of salt iodising in the food supply. We examined both the availability and sale of (non-)iodised salt. Average sales-weighted iodine levels in salt were calculated using the results of a national monitoring of salt quality. Data on the availability and sales of salts were collected in major food retailers in 2014. Iodised salt represented 59.2% of the salt samples, and 95.9% of salt sales, with an average (sales-weighted) level of 24.2 mg KI/kg of salt. The average sales-weighted KI level in non-iodised salts was 3.5 mg KI/kg. We may conclude that the sales-weighted average iodine levels in iodised salt are in line with the regulatory requirements. However, the regulatory changes and the EU single market have considerably affected the availability of non-iodised salt. While sales of non-iodised salt are still low, non-iodised salt represented 33.7% of the salts in our sample. This indicates the existence of a niche market which could pose a risk of inadequate iodine intake in those who deliberately decide to consume non-iodised salt only. Policymakers need to provide efficient salt iodisation intervention to assure sufficient iodine supply in the future. The reported sales-weighting approach enables cost-efficient monitoring of the iodisation of salt in the food supply. Full article

(This article belongs to the Special Issue Fortification to Combat Micronutrient Deficiencies)

188 KiB

Open AccessCommunication

Iron, Anemia, and Iron Deficiency Anemia among Young Children in the United States

by Priya M. Gupta, Cria G. Perrine, Zuguo Mei and Kelley S. Scanlon

Nutrients 2016, 8(6), 330; https://doi.org/10.3390/nu8060330 - 30 May 2016

Cited by 101 | Viewed by 20671 | Correction

Abstract

Iron deficiency and anemia are associated with impaired neurocognitive development and immune function in young children. Total body iron, calculated from serum ferritin and soluble transferrin receptor concentrations, and hemoglobin allow for monitoring of the iron and anemia status of children in the United States. The purpose of this analysis is to describe the prevalence of iron deficiency (ID), anemia, and iron deficiency anemia (IDA) among children 1–5 years using data from the 2007–2010 National Health and Nutrition Examination Survey (NHANES). Prevalence of ID, anemia, and IDA among children 1–5 years was 7.1% (5.5, 8.7), 3.9% (2.0, 4.3), and 1.1% (0.6, 1.7), respectively. The prevalence of both ID and anemia were higher among children 1–2 years (p < 0.05). In addition, 50% of anemic children 1–2 years were iron deficient. This analysis provides an update on the prevalence of ID, anemia, and IDA for a representative sample of US children. Our results suggest little change in these indicators over the past decade. Monitoring of ID and anemia is critical and prevention of ID in early childhood should remain a public health priority. Full article

(This article belongs to the Special Issue Fortification to Combat Micronutrient Deficiencies)

1013 KiB

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Diet Quality and Adequacy of Nutrients in Preschool Children: Should Rice Fortified with Micronutrients Be Included in School Meals?

by Ceres M. Della Lucia, Kellen Cristina C. Rodrigues, Vivian Cristina C. Rodrigues, Laura Luiza M. Santos, Leandro M. Cardoso, Hércia S. D. Martino, Sylvia C. C. Franceschini and Helena Maria Pinheiro-Sant’Ana

Nutrients 2016, 8(5), 296; https://doi.org/10.3390/nu8050296 - 14 May 2016

Cited by 9 | Viewed by 6407

Abstract

Feeding is indicative of the nutritional status of children, however micronutrient deficiency is common in this age group. We evaluated the impact of inclusion of rice (Ultra Rice^® (UR^®)) fortified with iron, zinc, thiamin and folic acid on laboratory measurements and the nutrient intake of children. Ninety-nine preschoolers (2–6 years; 42.6% male) from two preschools participated, one of which received UR^® added to polished rice as part of school meals (test preschool) and the other received only polished rice (control preschool). Biochemical evaluations were performed before and after four months of intervention. Feeding was assessed by direct weighing of food, complemented by 24-h recalls, and the diet was assessed by the Healthy Eating Index (HEI) adapted to the Brazilian reality. The fortified rice improved the levels 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 inadequacy percentages of thiamine, folic acid and iron were lower among preschoolers from the test preschool. This study demonstrated the effectiveness of using UR^® on laboratory measurements of children. The inadequate intake of thiamine, folic acid and iron was also reduced, making the fortified rice an interesting strategy in school feeding programs. Full article

(This article belongs to the Special Issue Fortification to Combat Micronutrient Deficiencies)

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The Effects of an Oil and Wheat Flour Fortification Program on Pre-School Children and Women of Reproductive Age Living in Côte d’Ivoire, a Malaria-Endemic Area

by Fabian Rohner, Giovanna Raso, Sassor Odile P. Aké-Tano, Andreas B. Tschannen, Christopher Guy Nicholas Mascie-Taylor and Christine A. Northrop-Clewes

Nutrients 2016, 8(3), 148; https://doi.org/10.3390/nu8030148 - 7 Mar 2016

Cited by 9 | Viewed by 7250

Abstract

Anemia and micronutrient deficiencies are widespread in sub-Saharan Africa, but the impact of food fortification is still debated. The objective of this study was to estimate the iron and vitamin A status of preschool children (PSC) and women of reproductive age (WRA) in households consuming fortified oil and wheat flour. The survey was cross-sectional in a rural and an urban area. Data on demographics, socioeconomic status, and fortified foods were collected at households. Hemoglobin (Hb), retinol binding protein (RBP), ferritin, soluble transferrin receptors (sTfR), subclinical inflammation, and Plasmodium spp. infection data were collected. In PSC, vitamin A deficiency (VAD) was prevalent, but for each 1 mg retinol equivalents (RE)/kg of oil consumed, RBP increased by 0.37 μmol/L (p = 0.03). In WRA, there was no significant VAD in the population (0.7%). Anemia was found in 92.2% of rural and 56.3% of urban PSC (p < 0.001). PSC with access to adequately fortified flour had Hb concentrations 15.7 g/L higher than those who did not (p < 0.001). Hb levels increased by +0.238 g/L per mg/kg increase in iron fortification levels (p < 0.001). The national program fortifying vegetable oil with vitamin A and wheat flour with iron and folic acid may have contributed to improved micronutrient status of PSC from two areas in Côte d’Ivoire. Full article

(This article belongs to the Special Issue Fortification to Combat Micronutrient Deficiencies)

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20680 KiB

Open AccessFeature PaperReview

Assessment of the Dietary Intake of Schoolchildren in South Africa: 15 Years after the First National Study

by Nelia Steyn, Gabriel Eksteen and Marjanne Senekal

Nutrients 2016, 8(8), 509; https://doi.org/10.3390/nu8080509 - 19 Aug 2016

Cited by 12 | Viewed by 8482

Abstract

There has not been a national dietary study in children in South Africa since 1999. Fortification of flour and maize meal became mandatory in October 2003 to address micronutrient deficiencies found in the national study in 1999. The purpose of this review was to identify studies done after 1999 in schoolchildren, 6–15 years old, in order to determine whether dietary intakes reflected improvements in micronutrients, namely: iron, zinc, vitamin A, folate, thiamine, riboflavin, vitamin B6, and niacin. An electronic and hand search was done to identify all studies complying with relevant inclusion criteria. The search yielded 10 studies. Overall, there is a paucity of dietary studies which have included the fortified nutrients; only four, of which only one, reported on all micronutrients; making it difficult to determine whether fortification has improved the micronutrient intake of schoolchildren. This is further complicated by the fact that different dietary methods were used and that studies were only done in three of the nine provinces and thus are not generalizable. The results of these studies clearly point to the importance of doing a national study on the dietary intake of schoolchildren in order to confirm the outcomes of the fortification process. Full article

(This article belongs to the Special Issue Fortification to Combat Micronutrient Deficiencies)

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234 KiB

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Iron Fortification of Foods for Infants and Children in Low-Income Countries: Effects on the Gut Microbiome, Gut Inflammation, and Diarrhea

by Daniela Paganini, Mary A. Uyoga and Michael B. Zimmermann

Nutrients 2016, 8(8), 494; https://doi.org/10.3390/nu8080494 - 12 Aug 2016

Cited by 86 | Viewed by 11341

Abstract

Iron deficiency anemia (IDA) is common among infants and children in Sub-Saharan Africa and is a leading contributor to the global burden of disease, as well as a hindrance to national development. In-home iron fortification of complementary foods using micronutrient powders (MNPs) effectively reduces the risk for IDA by ensuring that the iron needs of infants and young children are met without changing their traditional diet. However, the iron dose delivered by MNPs is high, and comparable on a mg iron per kg body weight to the supplemental doses (2 mg/kg) typically given to older children, which increases diarrhea risk. In controlled studies, iron-containing MNPs modestly increase risk for diarrhea in infants; in some cases, the diarrhea is severe and may require hospitalization. Recent in vitro and in vivo studies provide insights into the mechanism of this effect. Provision of iron fortificants to school-age children and iron-containing MNPs to weaning infants decreases the number of beneficial ‘barrier’ commensal gut bacteria (e.g., bifidobacteria), increases the enterobacteria to bifidobacteria ratio and abundances of opportunistic pathogens (e.g., pathogenic Escherichia coli), and induces gut inflammation. Thus, although iron-containing MNPs are highly effective in reducing IDA, they may increase gastrointestinal morbidity in infants, and safer formulations are needed. Full article

(This article belongs to the Special Issue Fortification to Combat Micronutrient Deficiencies)

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Micronutrient Fortified Condiments and Noodles to Reduce Anemia in Children and Adults—A Literature Review and Meta-Analysis

by Sascha Hess, Linda Tecklenburg and Klaus Eichler

Nutrients 2016, 8(2), 88; https://doi.org/10.3390/nu8020088 - 15 Feb 2016

Cited by 13 | Viewed by 10754

Abstract

Micronutrient deficiencies impose a considerable burden of disease on many middle and low income countries. Several strategies have been shown to be effective in improving micronutrient deficiencies. However, the impact of fortified condiments as well as fortified noodles is less well documented. We aimed to investigate existing evidence on the impact of micronutrient fortified condiments and noodles on hemoglobin, anemia, and functional outcomes in children and adults (age: 5 to 50 years). We conducted a literature review in electronic databases. In addition, we screened the homepages of relevant organizations and journals. We included randomized controlled trials (RCT). Of 1046 retrieved studies, 14 RCT provided data for the meta-analysis. Micronutrient fortification of condiments and noodles increased hemoglobin concentrations by 0.74 g/dL (95%-confidence intervals (95%-CI): 0.56 to 0.93; 12 studies) and 0.3 g/dL (95%-CI: 0.12 to 0.48; 1 study), respectively. Micronutrient fortification also led to a reduced risk of having anemia (risk ratio 0.59 (95%-CI 0.44 to 0.80)). Ferritin concentrations increased with fortified condiments. Functional outcomes were rarely assessed and showed mixed results. The use of micronutrient fortified condiments can be a strategy to reduce anemia in children and adults due to micronutrient deficiencies. The effect of fortified noodles seems to be smaller. Full article

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Open AccessCorrection

Correction: Gupta, P.M.; et al. Iron, Anemia, and Iron Deficiency Anemia among Young Children in the United States Nutrients 2016, 8, 330

by Priya M. Gupta, Cria G. Perrine, Zuguo Mei and Kelley S. Scanlon

Nutrients 2017, 9(8), 876; https://doi.org/10.3390/nu9080876 - 15 Aug 2017

Cited by 7 | Viewed by 3754

Abstract

We would like to submit the following correction to our recently published paper [1] due to the error in classification of children as anemic [...] Full article

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