Impact Of Fortification Research Articles

The Challenge of Regulating Health Claims and Food Fortification

The Food and Drug Administration has several options that will assist the Public Health Service in implementing its September 1992 recommendation that all women of childbearing age consume 0.4 mg of folic acid dail to reduce their risk of having a pregnancy affected with a neural tube defect. The FDA can authorize the use of a health claim on labels and in the labeling of foods that characterizes the relationship between a nutrient and a health-related condition. Fortification of cereal-grain products with folic acid is a second option that has the potential for reaching most women of childbearing age without requiring them to change their food selection patterns. Consideration of these options has been intertwined with rapid developments in the scientific database that is the foundation of the health claim, by conflicting opinions regarding the effectiveness for women in the target population of FDA’s proposed level of cereal-grain fortification, by lack of systematic safety data regarding the impact of fortification on persons in the general population and by changes in the regulatory environment in which the agency acts.

Vitamin D Serum Levels in the UK Population, including a Mathematical Approach to Evaluate the Impact of Vitamin D Fortified Ready-to-Eat Breakfast Cereals: Application of the NDNS Database.

Vitamin D status is relatively poor in the general population, potentially leading to various conditions. The present study evaluates the relationship between vitamin D status and intake in the UK population and the impact of vitamin D fortified ready-to-eat cereals (RTEC) on this status via data from the National Diet and Nutrition Survey (NDNS: 2008–2012). Four cohorts were addressed: ages 4–10 (n = 803), ages 11–18 (n = 884), ages 19–64 (n = 1655) and ages 65 and higher (n = 428). The impact of fortification by 4.2 μg vitamin D per 100 g of RTEC on vitamin D intake and status was mathematically modelled. Average vitamin D daily intake was age-dependent, ranging from ~2.6 (age range 4–18 years) to ~5.0 μg (older than 64 years). Average 25(OH)D concentration ranged from 43 to 51 nmol/L, the highest in children. The relationship between vitamin D intake and status followed an asymptotic curve with a predicted plateau concentration ranging from 52 in children to 83 nmol/L in elderly. The fortification model showed that serum concentrations increased with ~1.0 in children to ~6.5 nmol/L in the elderly. This study revealed that vitamin D intake in the UK population is low with 25(OH)D concentrations being suboptimal for general health. Fortification of breakfast cereals can contribute to improve overall vitamin D status.

Pollen beverage from date palm spathe: impact of fortification with ginger on the nutritional and sensory quality of the product

Date palm spathes are by-products of date cultivation, which normally go to waste. To improve sustainability, this study reports the development of a date palm pollen beverage prepared from date palm spathes and examines the impact of ginger and pollen grains on its nutritional and sensory properties. Date spathe pollen beverage fortified with 1% ginger exceeded all other beverages in total protein, fat, carbohydrate, vitamin C, Mn, and Fe contents (P < 0.05). The unfortified date palm pollen beverage displayed the highest values of Bo, Co, Ni, Cu, Zn, Mb, color, flavor, texture, appearance, and overall quality (P < 0.05). The pollen beverage supplemented with 1% ginger and 1% pollen grains exhibited the highest antioxidant activity (P < 0.05). Overall, fortification of date palm pollen beverage with ginger showed a varied impact as it improved some nutritional properties, but compromised others and had a negative impact on the sensory quality of the product.

Prevalencia de defectos del tubo neural y estimación de casos evitados posfortificación en Argentina

Periconceptional intake of folic acid has demonstrated to be effective to reduce the frequency of neural tube defects, and food fortification has been one of the strategies implemented to increase it. An update is herein presented on the reduced prevalence of neural tube defect cases in the post-fortification period in Argentina and an estimation of cases averted in the 2005-2013 period as a result of this intervention. When comparing the prevalence observed in the post-fortification period to that reported in the pre-fortification period, anencephaly and encephalocele decreased by 66%, and spina bifida, by 47%, which were significant reductions. The estimated number of cases averted was higher for anencephaly, followed by spina bifida; encephalocele showed the lowest number of cases averted given that the prevalence of this defect was smaller. The decrease observed in the prevalence supports findings from previous studies on the impact of fortification.

Impact of fortification with iron salts and vitamin A on the physicochemical properties of laboratory‐pasteurised toned milk and bioaccessibility of the added nutrients

The sensory and physicochemical attributes of pasteurised milk fortified with soluble ferric pyrophosphate (FPP) (25 mg/L iron) and vitamin A (2500 IU) were comparable to unfortified control samples. The heat coagulation time (HCT) of fortified milks was comparable to the control and exhibited a type A curve with HCT–pH maxima at the acidic side of the natural pH. The distribution pattern of iron in different milk fractions was similar in control and fortified milk samples. The bioaccessibility of iron, estimated through in vitro digestibility of milk fortified with vitamin A and iron, was found to be slightly higher than that of milk fortified with iron alone.

Predicted efficacy of the Palestinian wheat flour fortification programme: complementary analysis of biochemical and dietary data.

To utilize complementary biochemical and dietary data collected before the initiation of national flour fortification to (i) identify micronutrient insufficiencies or deficiencies and dietary inadequacies in Palestinian women and children in vulnerable communities and (ii) assess the suitability of the current wheat flour fortification formula. Quantitative dietary intake questionnaires were administered and fasting venous blood samples collected in randomly selected households in Gaza City and Hebron. The impact of fortification was simulated by estimating the additional micronutrient content of fortified wheat flour. Households in Gaza City and Hebron that were not receiving food aid from social programmes. Non-pregnant women (18-49 years) and children aged 36-83 months. The micronutrients with highest prevalence of insufficiency were vitamin D in women (84-97 % with serum 25-hydroxyvitamin D <50 nmol/l) and vitamin B12 in women and children (43-82 % with serum B12 <221 pmol/l). Deficiencies of vitamin A, Fe and Zn were also of public health concern. Current levels of wheat flour fortificants were predicted to improve, but not eliminate, micronutrient intake inadequacies. Modification of fortificant concentrations of vitamin D, thiamin, vitamin B12, Zn and folic acid may be indicated. Micronutrient insufficiencies or deficiencies and intake inadequacies were prevalent based on either biochemical or dietary intake criteria. Adjustments to the current fortification formula for wheat flour are necessary to better meet the nutrient needs of Palestinian women and children.

Concept of double salt fortification; a tool to curtail micronutrient deficiencies and improve human health status

Fortification of food with micronutrients such as vitamins and minerals is one of the main strategies used to combat micronutrient deficiencies. Fortification in common salt is a fruitful strategy because of the daily consumption of 5-12 g salt per person globally. Therefore double fortification of salt with iodine and iron could be a reasonable approach to prevent both iodine and iron deficiencies. It is reckoned that about two billion people are iodine-deficient worldwide. Iodine deficiency during pregnancy may affect the health status of both mother and fetus and increase infant mortality. Deficiencies of both these micronutrients during childhood affect somatic growth and cognitive and neurological function. Thyroid metabolism is negatively affected by iron deficiency and reduced effectiveness of iodine prophylaxis in areas of endemic goiter. High prevalence of iron deficiency among children may be reduced by the application of effective iodized salt programs. However, ensuring the stability and bioavailability of both iron and iodine as double-fortified salt is difficult. Iodine present in iodide or iodate form in dual-fortified salt is oxidized to free iodine in the presence of ferrous ions and oxygen and consequently loses its characteristics. Moreover, ferrous iron is more bioavailable but is readily oxidized to the less bioavailable ferric form. However, both forms of iron may lead to discoloration of the final product, which can be reduced by providing a physical barrier around the iron. Salt encapsulation is one of the best tools to provide a physical barrier for undesirable reactions and interactions during storage. In this review the concept of dual salt fortification, the impact of fortification on curing various life-threatening maladies, latest assessments of mineral deficiencies and the choice of fortificants are discussed.

Health needs assessment for congenital anomalies in middle-income countries: Examining the case for neural tube defects in Brazil.

Recent economic improvement in Brazil has been reflected in better maternal-child health indicators, with decreases in infant and perinatal mortality. However, under-five mortality due to congenital disorders remained unchanged, and congenital disorders have become the second leading cause of infant mortality. In the present study, we used the PHG Foundation Health Needs Assessment (HNA) Toolkit with the objective of first assessing the burden of disease caused by neural tube defects (NTDs) in Brazil and the impact of interventions already put in place to address the burden, and second to evaluate and prioritize further interventions and policies required for its prevention and treatment. The results from these two components of the HNA process are described in this paper. The published literature was reviewed to identify studies of NTDs (prevalence; morbidity; prenatal, perinatal, and postnatal mortality; treatment or prevention). Data on indicators of maternal and child health were obtained directly from the Brazilian Ministry of Health, through the online Live Births Information System (SINASC) and from the Mortality Information System (SIM). Descriptive analyses included reports of the rates of NTD in liveborns, fetal, and infant deaths. Differences between folic acid flour pre-fortification (2001-2004) and post-fortification (2006-2010) periods were expressed as prevalence rate ratios. Around 20% of fetal deaths were related to congenital disorders with approximately 5% of those being NTDs. For infant mortality, congenital disorders were notified in approximately 15% of cases, with NTDs present in 10% of the malformed children. Although statistically significant, the prevalence rate ratio (PRR) for spina bifida in live births was only 0.937 (95% confidence interval (CI) 0.884-0.994), a decrease of 6.3% when comparing the pre and post-fortification periods. The impact of fortification seemed to be more visible in fetal deaths due to anencephaly (PRR = 0.727, 95% CI 0.681-0.777) and for spina bifida (PRR = 0.700, 95% CI 0.507-0.967) with associated decreases of 27.3 and 30%. The lower impact of folic acid fortification in Brazil, compared to other Latin-American countries, can be due to differences in dietary habits, concentration of folic acid in flour, as well as characteristic population ethnic composition. The HNA led to the identification of the needs to be addressed in Brazil, including the improvement of reporting congenital disorders within the nationwide birth certification system, and revision of the policy of flour folic acid fortification.

The Importance of Using Food and Nutrient Intake Data to Identify Appropriate Vehicles and Estimate Potential Benefits of Food Fortification in Uganda

Concern over micronutrient inadequacies in Uganda has prompted the introduction of mass fortification. To use food intake to determine nutrient inadequacies in children aged 24 to 59 months and nonpregnant women of reproductive age, and to model the adequacy of mass fortification. Data were collected by the 24-hour recall method in three regions. Usual nutrient intakes were calculated by adjusting actual intake distribution for the intraindividual variance. The impact of fortification on intake adequacy was simulated. The nutrients with the highest prevalence of inadequate intake across regions were vitamin A (30% to 99%), vitamin B12 (32% to 100%), iron (55% to 89%), zinc (18% to 82%), and calcium (84% to 100%). According to simulations, fortification of vegetable oil and sugar with vitamin A would reduce the prevalence of vitamin A inadequacy in the Western and Northern regions; in Kampala it would eliminate vitamin A inadequacy but would cause 2% to 48% of children to exceed the Tolerable Upper Intake Level (UL). The proposed fortification of wheat flour would reduce the prevalence of inadequate intakes of thiamine, riboflavin, folate, and niacin in Kampala, but would have little impact in the other two regions due to low flour consumption. Micronutrient fortification of vegetable oil and sugar in all regions and of wheat flour in Kampala would reduce the prevalence of micronutrient inadequacies. However, the wheat flour formulation should be modified to better meet requirements, and the vitamin A content in sugar should be reduced to minimize the risk of high intakes. Maize flour may be suitable for targeted fortification, but prior consolidation of the industry would be required for maize flour to become a good vehicle for mass fortification.

Neural tube defects in Latin America and the impact of fortification: a literature review.

Data on the prevalence of birth defects and neural tube defects (NTD) in Latin America are limited. The present review summarizes NTD prevalence and time trends in Latin American countries and compares pre- and post-fortification periods to assess the impact of folic acid fortification in these countries. We carried out a literature review of studies and institutional reports published between 1990 and 2010 that contained information on NTD prevalence in Latin America. NTD prevalence in Latin American countries varied from 0·2 to 9·6 per 1000 live births and was influenced by methods of ascertainment. Time trends from Bogota, Costa Rica, Dominican Republic, Guatemala City, Mexico and Puerto Rico showed average annual declines of 2·5 % to 21·8 %. Pre- and post-fortification comparisons were available for Argentina, Brazil, Chile, Costa Rica, Puerto Rico and Mexico. The aggregate percentage decline in NTD prevalence ranged from 33 % to 59 %. The present publication is the first to review data on time trends and the impact of folic acid fortification on NTD prevalence in Latin America. Reported NTD prevalence varied markedly by geographic region and in some areas of Latin America was among the lowest in the world, while in other areas it was among the highest. For countries with available information, time trends showed significant declines in NTD prevalence and these declines were greater in countries where folic acid fortification of staples reached the majority of the population at risk, such as Chile and Costa Rica.

Survey of total folate intake at conception and assessment of impact of fortification

Background. In view of plans for dietary fortification with folic acid, there is a need to reassess the advice being given in primary care. Patients and professionals may assume that fortification will make preconceptional folic acid supplementation unnecessary, but this is unlikely to be correct.Aim. To calculate the intake of total folic acid and folate at conception and to estimate the impact of fortification on the incidence of neural tube defect (NTD) conceptions.Design. An in‐depth investigation of dietary folate intake of 18 women and a survey of preconception supplementation in a group of 130 women, including an assessment of the probable impact of mandatory fortification.Method. Dietary folate intake of six infertile women and 12 age‐matched fertile controls was assessed using a 7‐day weighed diet diary. Mean values for this group were used as an estimate of local dietary folate intake. Questionnaires about periconceptional intake of supplements that included folic acid in their formulation were ...

Wheat Flour Fortification Is Unlikely to Benefit the Neediest in Guatemala

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

Are Encephaloceles Neural Tube Defects?

Encephalocele is classified as a neural tube defect, but questions have been raised regarding whether its epidemiological characteristics are similar to those of other neural tube defects. We compared characteristics of temporal trends in, and the impact of folic acid grain fortification on, the prevalence of encephalocele, spina bifida, and anencephaly using data from the Metropolitan Atlanta Congenital Defects Program, a population-based birth defects surveillance system. Prevalences of encephalocele, spina bifida, and anencephaly were compared by maternal age, gender, race, birth weight, ascertainment period (1968-1981, 1982-1993, or 1994-2002), and fortification period (1994-1996 [prefortification] and 1998-2002 [postfortification]) using prevalence ratios with 95% confidence intervals. Temporal trends were assessed using Poisson and negative binomial regression models. Prevalence rates of encephalocele (n = 167), spina bifida (n = 650), and anencephaly (n = 431) were 1.4, 5.5, and 3.7 per 10 000 live births, respectively. Encephalocele was similar to anencephaly in showing an increased prevalence among girls and multiple gestation pregnancies and to spina bifida and anencephaly in an annual prevalence decrease between 1968 and 2002 (-1.2% for encephalocele, -4.2% for spina bifida, and -3.6% for anencephaly). With fortification, prevalence decreased for spina bifida but not significantly for encephalocele or anencephaly. Encephalocele shows more similarities to spina bifida or anencephaly than it shows differences with respect to characteristics, temporal trend, and impact of fortification. Additional studies should be done to explore the etiologic heterogeneity of encephalocele using better markers of folate status and a wider range of risk factors.

The Impact of Fortification with Conjugated Linoleic Acid (CLA) on the Quality of Fluid Milk

The effects of added conjugated linoleic acid (CLA) on the sensory, chemical, and physical characteristics of 2% total fat (wt/wt) fluid milk were studied. Milks with 2% (wt/wt) total fat (2% CLA, 1% CLA:1% milkfat, 2% milkfat) were made by the addition of cream or CLA triglyceride oil into skim milk followed by HTST pasteurization and homogenization. The effects of adding vitamin E (200ppm) and rosemary extract (0.1% wt/wt based on fat content) were investigated to prevent lipid oxidation. HTST pasteurization resulted in a significant decrease of the cis-9/trans-11 isomer and other minor CLA isomers. The cis-9/trans-11 isomer concentration remained stable through 2 wk of refrigerated storage. A significant loss of both the cis-9/trans-11 and the cis-10/trans-12 isomers occurred after 3 wk of refrigerated storage. The loss was attributed to lipase activity from excessive microbial growth. No differences were found in hexanal or other common indicators of lipid oxidation between milks with or without added CLA (P>0.05). Descriptive sensory analysis revealed that milks with 1 or 2% CLA exhibited low intensities of a “grassy/vegetable oil” flavor, not present in control milks. The antioxidant treatments were deemed to be ineffective, under the storage conditions of this study, and did not produce significant differences from the control samples (P>0.05). CLA-Fortified milk had significantly lower L* and b* values compared with 2% milkfat milk. No significant differences existed in viscosity. Consumer acceptability scores (n = 100) were lower (P<0.05) for CLA-fortified milks compared to control milks, but the addition of chocolate flavor increased acceptability (P<0.05).

CME Paper: Homocysteine: The New Risk Factor for Cardiovascular Disease in the Elderly.

Higher levels of plasma homocysteine are associated with a variety of atherosclerotic conditions that are particularly pertinent to elderly persons. Cross sectional data have suggested that the lower deciles of plasma and dietary folate are highly associated with the presence of carotid stenosis in the elderly. Recent prospective studies have demonstrated strong associations between elevated concentrations of homocysteine and the incidence of cardiovascular mortality, total mortality, and stroke in elderly men and women. The impact of folate fortification on homocysteine levels has been assessed in middle-aged adults, but the clinical impact of fortification or supplementation of the diet with folate on clinical end points of cardiovascular disease is presently unknown, although clinical trials with folate supplementation are underway. (c) 2000 by CVRR, Inc.

Fortification of sugar with iron sodium ethylenediaminotetraacetate (FeNaEDTA) improves iron status in semirural Guatemalan populations

A 32-mo-long, double-blind field study involving one highland control community receiving only vitamin A-fortified sugar and three vitamin A- and FeNaEDTA-sugar-fortified communities, two in the lowlands and one in the highlands of Guatemala, was undertaken to test the effectiveness of this approach in controlling iron deficiency. The communities' population ranged between 1200 and 17000. Sugar fortified with 1 g FeNaEDTA and 15 mg retinol as retinyl palmitate/kg was stable, did not segregate, and was well accepted by the communities. The impact of fortification on iron nutrition was estimated at 8, 20, and 32 mo of intervention. All pregnant women and subjects with severe anemia received supplements or treatment and were excluded from the analysis. Iron stores in the fortified communities increased significantly except for women 18-48 y of age in one lowland community and > 49 y in the highland community. Iron stores in the control community remained unchanged except for a rise among adult males.