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.

Different feeding regimens were not associated with variation in body composition in preterm infants

AIM

The aim was to determine body composition and growth in preterm infants based on two different feeding regimens and to assess how standard and individual fortification (IF) affect energy and protein intake. Body composition was assessed at full term and at four months corrected age.

METHODS

Sixty preterm infants born before gestational week 32 were randomized either to IF of mother's breast milk after it had been analyzed or to standard fortification (SF) of mother's breast milk based on the average protein and energy content of breast milk. Body composition was measured at full term and at four months corrected age, using air displacement plethysmography. Growth rate and nutritional intake analyses were also conducted.

RESULTS

At 40 weeks gestational age, there was no difference between weight (g) (IF 3056 ± 472 vs. SF 3119 ± 564), body fat (%) (IF 19 ± 3.3 vs. SF 21 ± 5.6), fat mass, or fat-free mass between the two groups. Furthermore, there was no difference between the groups in weight, length, head circumference, or body composition at four months corrected age.

CONCLUSIONS

Fortification based on breast milk analysis may not improve growth in preterm infants compared to SF. However, both groups were smaller and had a different body composition at term corrected age compared to infants born at term.

Effects of duration and supplementation dose with astaxanthin on egg fortification

Long-term and graded dose of astaxanthin supplementation in laying hen's diet was assessed for egg fortification. Five groups of laying hens with 8 replications each were fed for 24 wk with diet supplemented astaxanthin at 0 mg/kg (control), 7.1 mg/kg, 14.2 mg/kg, 21.3 mg/kg, and 42.6 mg/kg (Basal, A7, A14, A21, and A42, respectively). The performance of laying hens, egg quality, astaxanthin concentration as well as conversion efficiency and geometric isomers proportion in yolks were assessed on wk 8 and 24. One-way analysis of variance (ANOVA) and linear and quadratic regression analyses were used to evaluate the dose effect. In parallel, the Student's t test compared the values between wk 8 and wk 24 of test within a group. Overall, the results revealed that neither production performance nor egg physical quality was affected by astaxanthin dose level and feeding duration. Following the supplementation dose, the redness of yolks (a*) increased (P < 0.001). But, the a* score in A42 (23.48) was just 3-folds the a* score in A7 (8.89). Concentration of astaxanthin in eggs was dose-level dependent showing a linear relationship (P < 0.001) with a slight declination observed in all groups on wk 24 compared to wk 8. The deposition rate of astaxanthin into egg yolk was higher in A21 and A42. The proportion of geometric isomers in egg yolk were not affected by the feeding duration. As the supplementation dose increased, all-trans isomer proportion gradually decreased in the egg yolk, while 13-cis isomer proportion rose. It was concluded that astaxanthin is an efficient carotenoid for egg fortification, which can be supplemented in diet up to 42.6 mg/kg for 24 wk without compromising the performance of laying hens or physical quality of eggs. This appreciably affects the egg yolk color and confers a better accumulation of total astaxanthin and cis isomers into eggs as the supplementation dose increases.

Enhancing health benefits of milled rice: current status and future perspectives

Milled rice is an essential part of the regular diet for approximately half of the world's population. Its remarkable commercial value and consumer acceptance are mostly due to its promising cooking qualities, appealing sensory properties, and longer shelf life. However, the significant loss of the nutrient-rich bran layer during milling makes it less nutritious than the whole grain. Thus, enhancing the nutritive value of milled rice is vital in improving the health and wellbeing of rice consumers, particularly for those residing in the low-economic zones where rice is the primary source of calories and nutrition. This article provides a critical review on multiple frontiers of recent interventions, such as (1) infusing the genetic diversity to enrich amylose and resistant starch to reduce glycaemic index, (2) enhancing the minerals and vitamins through complementary fortification and biofortification as short and long-term interventions, and (3) developing transgenic solutions to improve the nutrient levels of milled rice. Additionally, the review highlights the benefits of functional ingredients of milled rice to human health and the potential of enhancing them in rice to address the triple burden of malnutrition. The potential merit of milled rice concerning food safety is also reviewed in this article.

Feasibility of commercial breadmaking using chickpea as an ingredient: Functional properties and potential health benefits

The use of pulses, such as chickpea, has become more relevant in baking as they exhibit potential health benefits such as reduction of obesity, type 2 diabetes, and prevention of colon cancer. It is also a good source of highly bioavailable protein at a low cost. This allows companies to develop new innovative products that meet the demand for nutritional value-added baked goods. Further understanding of the baking properties and rheology of chickpea flours will allow the baking industry to overcome processing and quality challenges related to the effects caused by the addition of non-gluten-forming ingredients. Therefore, the objective of this review was to summarize the rheological properties of baking formulations using chickpea as an ingredient in order to produce quality products while preserving the nutritional aspects of this legume. It also covers health benefits linked to chickpea-specific compounds.

Biofortified and fortified maize consumption reduces prevalence of low milk retinol, but does not increase vitamin A stores of breastfeeding Zambian infants with adequate reserves: a randomized controlled trial

BACKGROUND

Replacement of conventional staples with biofortified or industrially fortified staples in household diets may increase maternal breast milk retinol content and vitamin A intakes from complementary foods, improving infant total body stores (TBS) of vitamin A.

OBJECTIVES

To determine whether biofortified or industrially fortified maize consumption by Zambian women and their breastfeeding infants could improve milk retinol concentration and infant TBS.

METHODS

We randomly assigned 255 lactating women and their 9-mo-old infants to a 90-d intervention providing 0 µg retinol equivalents (RE)/d as conventional maize or ∼315 µg RE/d to mothers and ∼55 µg RE/d to infants as provitamin A carotenoid-biofortified maize or retinyl palmitate-fortified maize. Outcomes were TBS, measured by retinol isotope dilution in infants (primary), and breast milk retinol, measured by HPLC in women (secondary).

RESULTS

The intervention groups were comparable at baseline. Loss to follow-up was 10% (n = 230 mother-infant pairs). Women consumed 92% of the intended 287 g/d and infants consumed 82% of the intended 50 g/d maize. The baseline geometric mean (GM) milk retinol concentration was 1.57 μmol/L (95% CI: 1.45, 1.69 μmol/L), and 24% of women had milk retinol <1.05 μmol/L. While mean milk retinol did not change in the biofortified arm (β: 0.11; 95% CI: -0.02, 0.24), the intervention reduced low milk retinol (RR: 0.42; 95% CI: 0.21, 0.85). Fortified maize increased mean milk retinol (β: 0.17; 95% CI: 0.04, 0.30) and reduced the prevalence of low milk retinol (RR: 0.46; 95% CI: 0.25, 0.82). The baseline GM TBS was 178 μmol (95% CI: 166, 191 μmol). This increased by 24 µmol (± 136) over the 90-d intervention period, irrespective of treatment group.

CONCLUSIONS

Both biofortified and fortified maize consumption improved milk retinol concentration. This did not translate into greater infant TBS, most likely due to adequate TBS at baseline. This trial was registered at clinicaltrials.gov as NCT02804490.

Bread Fortified with Cooked Purple Potato Flour and Citrus Albedo: An Evaluation of Its Compositional and Sensorial Properties

This research aimed to explore the feasibility of fortifying bread with cooked Vitelotte potato powder and Citrus albedo, comparing the use of baker's yeast or sourdough as leavening agents. Breads obtained were thus subjected to physico-chemical and sensory characterizations. The replacement of part of the wheat flour with purple potato and albedo determined a significant enhancement of the phenolic profile and antioxidant status of fortified breads, as well as a longer shelf life. Thanks to its acidity and antimicrobial activity, sourdough improved the levels of health-promoting compounds and stability. Both the fortification and the leavening agent deeply affected the organoleptic, expression, and the aroma profile, of the fortified bread. Interestingly, albedo addition, despite its effectiveness in boosting the phenolic profile, determined a higher perception of aftertaste and bitterness, irrespective of the leavening agent. Based on these results, the use of purple potatoes and Citrus albedo, if properly formulated, could represent a valuable strategy for the development of high-quality products, with longer shelf-life.

Early fortification of enteral feedings for infants <1250 grams birth weight receiving a human milk diet including human milk based fortifier

BACKGROUND

An exclusive human milk diet (EHM) including fortification with a human milk-based fortifier has been shown to decrease the occurrence of necrotizing enterocolitis (NEC) but growth velocity may be less for infants receiving EHM compared to a bovine diet.

OBJECTIVE

The objective of this study was to determine if growth is improved by earlier fortification of breast milk for preterm infants supported with a human milk based fortifier.

STUDY DESIGN

A multi-center retrospective cohort study of the outcomes of infants of 500- 1250 g birth weight whose breast milk feedings were fortified at >60 mL/kg/day (late) versus <60 mL/kg/day (early) of enteral feeding volume.

RESULTS

Median±IQR range for gestational age (27.6±3.4 vs 27.0±2.9 weeks, p = 0.03) and chronic lung disease (CLD: 42.6 vs 27.6%, p = 0.008) were higher, and weight gain (12.9±2.6 vs 13.3±2.6 g/kg/day, p = 0.03) was lower in the late (N = 102) vs the early (N = 292) group. Adjusted multiple linear regression analysis found that early fortification was associated with improved growth velocity for weight (p = 0.007) and head circumference (HC) (p = 0.021) and less negative changes in z-scores for weight (p = 0.022) and HC (p = 0.046) from birth to discharge. Adjusted multiple logistic regression found that early fortification was associated with decreased occurrence of CLD (p = 0.004). No other outcomes, including NEC, were associated with early versus late fortification.

CONCLUSION

The study results suggested that early HM fortification appears to positively affect growth for infants whose human milk feedings are fortified with a human milk based fortifier without adverse effects. The incidence of CLD was also reduced in the early fortification group.

Prenatal and Early Life Exposure to the Danish Mandatory Vitamin D Fortification Policy Might Prevent Inflammatory Bowel Disease Later in Life: A Societal Experiment

This register-based national cohort study of 206,900 individuals investigated whether prenatal exposure to small extra doses of vitamin D from fortified margarine prevented inflammatory bowel disease (IBD) later in life; whether the risk of IBD varied according to month or season of birth; and finally, whether there was an interaction between exposure to extra D vitamin and month or season of birth. Fortification of margarine with vitamin D was mandatory in Denmark from the mid-1930s until 1st June 1985, when it was abolished. Two entire birth cohorts, each including two years, were defined: one exposed and one unexposed to the fortification policy for the entire gestation. All individuals were followed for 30 years from the day of birth for an IBD diagnosis in Danish hospital registers. Logistic regression analyses were used to estimate odds ratios (OR) and 95% confidence intervals (CI). Odds for IBD was lower among those exposed to extra D vitamin compared to those unexposed, OR = 0.87 (95% CI: 0.79; 0.95). No association with month or season of birth was found. However, estimates suggested that particularly children born during autumn may have benefitted from the effect of small extra doses of vitamin D. This is, to our knowledge, the first study to explore if prenatal exposure to vitamin D from fortification influenced the risk of IBD. Our results suggest that prenatal exposure to small amounts of extra vitamin D from food fortification may protect against the development of IBD before 30 years of age.

A Human Milk-Based Protein Concentrate Developed for Preterm Infants Retains Bioactive Proteins and Supports Growth of Weanling Rats

BACKGROUND

Bovine milk-based protein modulars are currently available to nutrient-enrich enteral feedings; however, they have limitations for use in very-low-birth-weight infants.

OBJECTIVES

Our objectives were to develop a human milk-based protein (HMP) concentrate and to conduct a preclinical assessment of the HMP concentrate in weanling rats.

METHODS

An HMP concentrate was produced from donor milk using pressure-driven membrane filtration processes and high hydrostatic pressure processing. Protein and lactoferrin concentrations and lysozyme activity were determined by Kjeldahl, HPLC, and turbidimetric assay, respectively. Male Sprague Dawley rats 24 d old (n = 30) were randomly assigned to 1 of 3 isocaloric AIN-93G diets for 4 wk containing 100% casein (control) or with 50% of the casein replaced with the HMP concentrate (treatment) or a bovine whey protein isolate (treatment). Body weight, food intake, fat mass, plasma amino acid profiles, and organ weights were measured. Data were analyzed using linear regression models.

RESULTS

Raw donor milk contained (mean ± SD) 101 ± 6 g protein/kg and 5 ± 1 g lactoferrin/kg of milk solids. Postprocessing, protein and lactoferrin concentrations were 589 ± 3 g/kg and 29 ± 10 g/kg, respectively. Lysozyme activity was initially 209 ± 4 U/kg and increased to 959 ± 39 U/kg in the HMP concentrate. There were no statistically significant differences in body weight, food intake, fat mass, or plasma amino acid profiles between rats fed diets containing the HMP concentrate and the control diet. Full cecum weights were higher in rats fed the HMP concentrate than in those fed control diets (mean difference: 5.59 g; 95% CI: 4.50, 6.68 g; P < 0.0001), likely reflecting the concentration of human milk oligosaccharides. No differences were found for other organ weights.

CONCLUSIONS

The HMP concentrate retained important bioactive proteins and supported normal rat growth in the preclinical assessment.

Examining Heterogeneity of Food Fortification and Biofortification Business Models: Emerging Evidence for a Typology

Efforts to address Micronutrient deficiencies (MNDs) in lower-and middle-income countries (LMICs) have been gaining pace in recent years. Commodities such as staple foods (e.g., cereals, roots, and tubers) and condiments (e.g., salt) have been targeted as ‘vehicles’ for fortification and biofortification through numerous projects and initiatives. To date, there have been mixed experiences with delivery and coverage with very little documented on the range of business models applied in different geographies, business conditions and polities and this makes classification and measurement of success and failure difficult. This research aims to address this gap in knowledge through proposing a typology that clarifies similarities (internal heterogeneity) and differences (external heterogeneity) between models and that can allow all types to be defined by the combination of attributes. Building on a comprehensive literature review; NVivo was used to code initiatives from 34 key references (955 cases in total) which have been grouped into 17 categories. Using non-metric multidimensional scaling (NMDS) we find evidence of four business model groupings that typify fortification initiatives: (1) Large-scale private, unregulated, (2) Mixed-Scale, private, unregulated (3) Large-scale, public-private, regulated; and (4) Large-scale, private, regulated. We characterise these four groups with country examples and suggest that this typology can help the discourse around viability of food fortification initiatives.

Vitamin A deficiency has declined in Malawi, but with evidence of elevated vitamin A in children

BACKGROUND

Reduction of vitamin A deficiency (VAD) in Malawi coincided with introduction of vitamin A-fortified staple foods, alongside continued biannual high-dose vitamin A supplementation (VAS).

OBJECTIVE

We describe coverage of vitamin A interventions and vitamin A status in the 2015-2016 Malawi Micronutrient Survey.

METHODS

Food samples and biospecimens were collected within a representative household survey across 105 clusters. Retinol was measured using ultraviolet excitation fluorescence (sugar) and photometric determination (oil). Preschool children (PSC, aged 6-59 mo, n = 1102), school-age children (SAC, aged 5-14 y, n = 758), nonpregnant women (n = 752), and men (n = 219) were initially assessed for vitamin A status using retinol binding protein (RBP) and modified relative dose response (MRDR). Randomly selected fasted MRDR participants (n = 247) and nonfasted women and children (n = 293) were later assessed for serum retinol, retinyl esters, and carotenoids. Analyses accounted for complex survey design.

RESULTS

We tested sugar and oil samples from 71.8% and 70.5% of the households (n = 2,112), respectively. All of the oil samples and all but one of the sugar samples had detectable vitamin A. National mean retinol sugar and oil contents were 6.1 ± 0.7 mg/kg and 6.6 ± 1.4 mg/kg, respectively. Receipt of VAS in the previous 6 mo was reported by 68.0% of PSC. VAD prevalence (RBP equivalent to <0.7µmol retinol/L) was 3.6% in PSC, and <1% in other groups. One woman and no children had MRDR ≥0.060 indicating VAD. Among fasted PSC and SAC, 18.0% (95% CI: 6.4, 29.6) and 18.8% (7.2, 30.5) had >5% of total serum vitamin A as retinyl esters, and 1.7% (0.0, 4.1) and 4.9% (0.0, 10.2) had >10% of total serum vitamin A as retinyl esters. Serum carotenoids indicated recent intake of vitamin A-rich fruits and vegetables.

CONCLUSIONS

Near elimination of VAD in Malawi is a public health success story, but elevated levels of vitamin A among children suggests that vitamin A interventions may need modification.

Modern India and Dietary Calcium Deficiency-Half a Century Nutrition Data-Retrospect-Introspect and the Road Ahead

Calcium and vitamin D are inseparable nutrients required for bone health. In the past half a century, the dietary calcium intake of rural, tribal, and urban India has declined. Though India is the largest producer of milk and cereals, the major source of calcium in India is through non-dairy products. The highest intake of cereals and lowest intake of milk & milk products was observed in rural and tribal subjects whereas, the intake of cereals, milk & milk products were similar in both urban and metropolitan subjects. One of the reasons for lower calcium intake was the proportion of calcium derived from dairy sources. Over the past half a century, the average 30-day consumption of cereals in the rural and urban population has declined by 30%. The Per Capita Cereal Consumption (PCCC)has declined despite sustained raise in Monthly Per capita Consumption Expenditure (MPCE) in both rural and urban households. The cereal consumption was the highest in the lowest income group, despite spending smaller portion of their income, as cereals were supplied through public distribution system (PDS). About 85% of the Indian population are vitamin D deficient despite abundant sunlight. Dietary calcium deficiency can cause secondary vitamin D deficiency. Though India as a nation is the largest producer of milk, there is profound shortage of calcium intake in the diet with all negative consequences on bone health. There is a decline in dietary calcium in the background of upward revision of RDI/RDA. There is a gap in the production-consumption-supply chain with respect to dietary calcium. To achieve a strong bone health across India, it is imperative to have population based strategies addressing different segments including supplementing dietary/supplemental calcium in ICDS, mid-day-meals scheme, public distribution system, educational strategies. Other measures like mass food fortification, biofortification, bioaddition, leveraging digital technologies, investments from corporate sector are some measures which can address this problem. India is a vast country with diverse social, cultural and dietary habits. No single measure can address this problem and requires a multi-pronged strategic approach to tackle the dietary calcium deficiency to achieve strong bone health while solving the problem of nutritional deficiency.

Formulation and characterization of catechin-loaded proniosomes for food fortification

BACKGROUND

To overcome the problems associated with niosomes, proniosomes - a dry powder - was prepared to nanoencapsulate catechins using Span 60 as surfactant, cholesterol as stabilizer and maltodextrin, lactose monohydrate and pullulan as wall materials. The proniosomes were made by the thin-film hydration technique, and were characterized for fortification in milk beverages. Scanning and atomic force microscopic images showed the varying morphology and ultrastructure of the proniosomes. The mean hydrodynamic diameter of 193.57-262.52 nm, polydispersity index of 0.24-0.25 and zeta potential of -15.8 to -24.73 were suggestive of the size, homogeneity and stability of the catechin-loaded proniosomes. X-ray powder diffractograms and Fourier transform infrared (FTIR) spectra provided insight about the interaction between catechins and wall materials. Entrapment efficiency and in vitro release were calculated to determine the extent of nanoencapsulation of catechins and their bioavailability, respectively. The nanoencapsulates were fortified in milk and yogurt to find their organoleptic acceptability.

RESULTS

Moisture content was found to be 20-30 g kg^-1 , indicating longer stability of the proniosomes. Scanning electron microscopic and atomic force microscopic images revealed the ultrastructure and spherical-shaped morphology of proniosomes. Entrapment efficiency of catechins using pullulan as wall material was as high as 83.43%. In vitro release studies revealed the sustained release of catechins from the proniosomes. FTIR and X-ray diffraction spectra revealed the absence of chemical interactions between catechins and encapsulants.

CONCLUSION

Food-grade proniosomes are a good vehicle for fortification of milk and yogurt without noticeable adverse changes in their organoleptic and physicochemical properties, thus increasing the potential for bioavailability of catechins in the gastrointestinal tract. © 2020 Society of Chemical Industry.

Overcoming bread quality decay concerns: main issues for bread shelf life as a function of biological leavening agents and different extra ingredients used in formulation. A review

As is widely accepted, the quality decay of freshly baked bread that affects product shelf life is the result of a complex multifactorial process that involves physical staling, together with microbiological, chemical and sensorial spoilage. In this context, this paper provides a critical review of the recent literature about the main factors affecting shelf life of bread during post-baking. An overview of the recent findings about the mechanism of bread staling is firstly provided. Afterwards, the effect on staling induced by baker's yeasts and sourdough as well as by the extra ingredients commonly utilized for bread fortification is also addressed and discussed. As inclusion/exclusion criteria, only papers dealing with wheat bread and not with long-life bread or gluten-free bakery products are taken into consideration. Despite recent developments in international scientific literature, the whole mechanism that induces bread staling is far from being completely understood and the best analytical methods to be adopted to measure and/or describe in depth this process appear still debated. In this topic, the effects induced on bread shelf life by the use of biological leavening agents (baker's yeasts and sourdough) as well as by some extra ingredients included in the bread recipe have been individuated as two key issues to be addressed and discussed in terms of their influence on the kinetics of bread staling. © 2020 Society of Chemical Industry.

Food Fortification: The Advantages, Disadvantages and Lessons from Sight and Life Programs

Deficiencies in one or more micronutrients such as iron, zinc, and vitamin A are widespread in low- and middle-income countries and compromise the physical and cognitive capacity of millions of people. Food fortification is a cost-effective strategy with demonstrated health, economic and social benefits. Despite ongoing debates globally and in some countries regarding the performance and safety of food fortification, the practice offers significant benefits across each of the main vehicles for food fortification (large-scale food fortification, biofortification and point-of-use or home fortification) ranging from reducing the prevalence of nutritional deficiencies and economic benefits to societies and economies. Using Sight and Life's global and national experiences in implementing food fortification efforts, we demonstrate how different programs in LMICs have successfully addressed challenges with food fortification and in doing so, find that these efforts are most successful when partnerships are formed that include the public and private sector as well as other parties that can provide support in key areas such as advocacy, management, capacity building, implementation and regulatory monitoring.

Determination of an Acceptable Portion Size of Daal for a Bangladeshi Community-Based Iron Intervention in Adolescent Girls: A Feasibility Study

Widely consumed daal (lentils) in Bangladesh are an ideal vehicle for iron (Fe) fortification; however, an acceptable portion size in meals needs to be determined to carry out a community feeding study in at-risk adolescent girls. A non-randomized crossover trial was conducted with n = 100 Bangladeshi girls (12.9 ± 2.0 years of age). Two recipes (thin and thick) and three portion sizes (25 g, 37.5 g, 50 g of raw lentil) of daal were served with 250 g of cooked white rice in a counter-balanced manner over 12 weeks. Each meal was fed to participants 5 days/week for two weeks. Ratings of hunger, satiety, and palatability were measured before and after each meal using Visual Analog Scales (VAS). The thick preparation in the 37.5 g portion (~200 g cooked) elicited higher VAS ratings of hunger, satiety, and palatability compared to all other meals. The 50 g portion of the thin preparation had VAS ratings similar to those of the 37.5 g thick preparation. Consuming the 37.5 g portion of fortified daal would provide 6.9 mg Fe/day to girls in a community-based effectiveness study. This would meet ~86% and ~46% of the Recommended Dietary Allowance (RDA) for Fe for girls aged 9-13 and 14-18 years, respectively.

Local Foods Can Increase Adequacy of Nutrients Other than Iron in Young Urban Egyptian Women: Results from Diet Modeling Analyses

BACKGROUND

Nutrition transition and recent changes in lifestyle in Middle Eastern countries have resulted in the double burden of malnutrition. In Egypt, 88% of urban women are overweight or obese and 50% are iron deficient. Their energy, sugar, and sodium intakes are excessive, while intakes of iron, vitamin D, and folate are insufficient.

OBJECTIVE

This study aimed to formulate dietary advice based on locally consumed and affordable foods and determine the need for fortified products to meet the nutrient requirements of urban Egyptian women.

METHODS

Food intakes were assessed using a 4-d food diary collected from 130 urban Egyptian women aged 19-30 y. Food prices were collected from modern and traditional markets to calculate diet cost. Population-based linear and goal programming analyses (Optifood tool) were used to identify "limiting nutrients" and to assess whether locally consumed foods (i.e., consumed by >5% of women) could theoretically improve nutrient adequacy at an affordable cost (i.e., less than or equal to the mean diet cost), while meeting recommendations for SFAs, sugars, and sodium. The potential of hypothetical fortified foods for improving intakes of micronutrients was also assessed.

RESULTS

Iron was the most limiting nutrient. Daily consumption of fruits, vegetables, milk or yogurt, meat/fish/eggs, and tahini (sesame paste) were likely to improve nutrient adequacy for 11 out of 12 micronutrients modeled. Among fortified foods tested, iron-fortified rice, milk, water, bread, or yogurt increased the minimized iron content of the modeled diet from 40% to >60% of the iron recommendation.

CONCLUSIONS

A set of dietary advice based on locally consumed foods, if put into practice, can theoretically meet requirements for most nutrients, except for iron for which adequacy is harder to achieve without fortified products. The acceptability of the dietary changes modeled needs evaluation before promoting them to young Egyptian women.

International Analysis of the Nutritional Content and a Review of Health Benefits of Non-Dairy Plant-Based Beverages

Concerns about environmental impact and sustainability, animal welfare, and personal health issues have fueled consumer demand for dairy alternatives. The aim of this study was to conduct a cross-sectional survey of plant-based non-dairy beverages from three different continents (USA, Australia, and Western Europe) to assess their nutritional content and health profile. A total of 148 non-dairy beverages were analyzed from the nutrition label and ingredients listed on the commercial package or from the information located on the website of the manufacturer or retailer. The different types of beverages were extracts of nuts or seeds (n = 49), grains (n = 38), legumes (n = 36), coconut (n = 10), and mixed blends (n = 15). On average, the plant-based beverages generally scored well in terms of not containing high levels of sodium, saturated fat, or calories. Over half of the beverages were fortified with calcium to levels equal to or greater than that of dairy milk. The protein content varied from 0 to 10 g/serving. Levels of vitamin D and B12 fortification were quite low. Consumers should be informed of the nutritional profile and potential health benefits of plant-based dairy alternatives as the nutritional content can vary greatly between the different types of beverages.

Preterm infant nutrition and growth with a human milk diet

Human milk is the preferred enteral diet for preterm infants. It provides macronutrients, micronutrients, and bioactive factors that support physical growth and neurodevelopment. Challenges of the human milk diet include the variability in its composition and a need for fortification to mirror placental nutrient delivery and prevent extrauterine growth restriction. Various strategies exist to attain target nutrient provision and optimize growth, including leveraging new technology for point-of-care human milk analysis. When maternal milk is unavailable or in short supply, pasteurized donor human milk is the preferred alternative. Infants fed donor milk may have slower weight gain than those fed exclusively maternal milk or formula, whereas infants fed fortified maternal milk have similar weight gain to preterm formula-fed infants. Future directions include more rigorous characterization of the variation in human milk, further investigation of the clinical benefits of non-nutrient bioactive factors in milk, and novel approaches to optimize fortification.

Effectiveness of Food Fortification in Improving Nutritional Status of Mothers and Children in Indonesia

Food fortification programs have been conducted in several countries to overcome micronutrient deficiency and related problems with various degrees of effectiveness. Available information regarding the success of food fortification programs in some developing countries, including Indonesia, is still limited. Thus, this study conducts a systematic review of the effects of food fortification of mothers and children using biochemical and anthropometric measures focusing on linear growth. Three databases were used in the literature search, namely PubMed, Science Direct and Google Scholar. Fifteen articles were included for analysis from 517 studies found consisting of Indonesian and English articles published from 2000 to June 2020. Fortification of iron, vitamin A, and iodine can increase the level of hemoglobin, serum ferritin, and serum retinol and median urine iodine excretion, especially in toddlers and schoolchildren. However, multinutrient fortification interventions were associated with various effects on hemoglobin, serum ferritin, and serum retinol but a positive association was found with linear growth indicators in the form of body length for age. The effectiveness of food fortification in reducing the prevalence of stunting still needs more and stronger evidence through studies with large sample size and longer duration.

Fortification of set yogurt with passion fruit juice: Effects on fermentation kinetics, physicochemical properties, and functionality

With the purpose of developing an alternative set yogurt with high consumer acceptability, passion fruit juice, at levels that varied from 0 to 10%, was incorporated into set yogurt, and the effects on the fermentation kinetics, physicochemical properties, and functionality of set yogurt were evaluated. The results showed that the addition of passion fruit juice was simultaneously propitious for milk acidification in earlier fermentation stages and reduced the fermentation rate at later stages of fermentation. The phenolic compounds and pectin in passion fruit juice interacted with caseins to form soluble complexes, enhancing the gel strength of set yogurts by 7.5%. The aroma and flavor of the set yogurt was improved as well. However, with the addition of 10% passion fruit juice, the gel structure was destroyed, and the quality of the set yogurt was very degraded. More importantly, the addition of passion fruit juice increased the polyphenol content and significantly enhanced the antioxidant activity of the set yogurt. This investigation demonstrated the feasibility of fabricating passion fruit juice-enriched set yogurt and its superior quality compared with the corresponding normal product.

Key Considerations for Policymakers-Iodized Salt as a Vehicle for Iron Fortification: Current Evidence, Challenges, and Knowledge Gaps

Could DFS help prevent iron deficiency and anemia? Studies in controlled settings (efficacy) demonstrate that double-fortified salt (DFS; iron added to iodized salt) reduces the prevalence of anemia and iron deficiency anemia. Studies in program settings (effectiveness) are limited and reported differing levels of DFS coverage, resulting in mixed evidence of impact on anemia. What iron formulations are available and how do they affect iodized salt? Ferrous sulfate and encapsulated ferrous fumarate (both with various enhancers and/or coating materials) are the main iron formulations currently in use for DFS. Adding iron to iodized salt may lead to adverse changes in the product, specifically discoloration and losses in iodine content. These changes are greatest when the iodized salt used in DFS production is of low quality (e.g., contain impurities, has high moisture, and is of large crystal size). DFS requires iodized salt of the highest quality and a high-quality iron formulation in order to minimize adverse sensory changes and iodine losses. Appropriate packaging of iodized salt is also important to prevent losses. What is known about the minimum requirements to manufacture DFS? DFS producers must use high-quality refined iodized salt meeting the minimum standards for DFS production (which is higher than standards for salt intended for iodization alone), and an iron formulation for which there are rigid quality-assurance measures to ensure consistent quality and blending techniques. The actual proportion of iodized salt meeting the stringent requirements necessary for DFS production is unclear, but likely to be low in many countries, especially those with fragmented salt industries and a low proportion of industrially produced salt. What are the financial implications of adding iron to iodized salt? As a result of higher input costs both for input salt and the iron compound, DFS is more expensive to produce than iodized salt and thus has a higher production cost. Various grades of iodized salt are produced and consumed in different sectors of the market. Experience in India indicates that, on average, producing DFS costs 31-40 US dollars/metric ton or 0.03-0.04 US dollars/kg more than high-quality refined iodized salt. The exact impact of this production-level cost difference on profit margins and consumer price is specific to the conditions of different salt markets. Factors such as transport costs, customary wholesale and retail mark-ups, and taxes all vary greatly and need to be assessed on a case by case basis. Is DFS in alignment with salt-reduction efforts? The WHO has long recognized that salt iodization is an important public health intervention to achieve optimal iodine nutrition and is compatible with salt-reduction goals. Fortification of salt (with any nutrient) should not be used to justify or encourage an increase in salt intake to the public. Any effort to expand salt fortification to other nutrients should be done in close consultation with WHO and those working on salt reduction. What has been the experience with DFS delivery under different platforms? To date, DFS has been introduced into the retail market and in social safety net (primarily in India) programs, but sensory changes in DFS have been raised as concerns. The higher price for DFS has limited expansion in the retail market. In social safety net programs where the cost of DFS is subsidized for beneficiaries, programs must consider long-term resourcing for sustainability. Overall: The optimal production and delivery of DFS are still under development, as many challenges need to be overcome. There is a beneficial impact on hemoglobin in efficacy trials. Thus, if those conditions can be replicated in programs or the technology can be adapted to better fit current production and delivery realities, DFS may provide an effective contribution in countries that need additional food-fortification vehicles to improve iron intake.

The Double-Fortified Salt (Iodized Salt with Iron) Consultation: A Process for Developing Evidence-Based Considerations for Countries

The addition of iodine to edible salt has been one of the most important public health successes of the past half century, enabling most countries to achieve optimal iodine intake and protect the brains of unborn children from the adverse consequences of iodine deficiency. Salt has been an ideal vehicle for this effort because of its near universal and narrow range of consumption, relative ease of technology for salt iodization, and capacity for virtually all salt producers to add iodine. As a result of the success of salt iodization, there has been growing interest in using salt as a vehicle for other important micronutrients, particularly the addition of iron to iodized salt to produce double-fortified salt (DFS), to combat the persistent problem of iron deficiency and iron deficiency anemia. Because of this growing interest in DFS and the need for a comprehensive review of evidence to support the viability of this intervention, the Iodine Global Network (IGN) initiated a global consultation to gather all available data on different aspects of DFS. IGN identified 4 key areas considered essential to understand for a successful fortification intervention: 1) efficacy and effectiveness, or how well DFS produces a health impact in controlled and real-life settings; 2) technical considerations for production, or what are the minimum requirements to manufacture DFS; 3) program implementation to describe experiences thus far with the delivery of DFS across multiple platforms; and 4) comparison of DFS with other iron fortification efforts to determine the comparative advantage of DFS to improve iron intake and prevent iron deficiency anemia. This preface provides an overview of the DFS Consultation objectives, process, and objectives.

Evaluation of Global Experiences in Large-Scale Double-Fortified Salt Programs

BACKGROUND

Double-fortified salt (DFS) is a vehicle for dual fortification with iron and iodine, to reduce their respective deficiencies. This background article is the third in a series reviewing available research, analyses, and experiences on DFS as an effective delivery vehicle for iron and iodine.

OBJECTIVES

The objective of this article is to systematically evaluate current programs distributing DFS around the world and catalogue opportunities, risks, and challenges related to programs that incorporate DFS. We carried out a narrative review of DFS programs from around the world with our data sources deriving from a mix of a nonsystematic literature search and interviews with key informants.

METHODS

We assessed programmatic experience with DFS from social safety net programs in India (from the states of Bihar, Madhya Pradesh, and Uttar Pradesh) and from non-social safety net country programs or projects in Argentina, Cote d'Ivoire, Kenya, Morocco, Nigeria, Philippines, and Sri Lanka.

RESULTS

Findings revealed color change of the final DFS product was an issue in 9 of the 14 programs or studies reviewed and was the most significant challenge that had a direct impact on consumer acceptance and uptake regardless of type of program (open market or social safety net). Other challenges identified were related to the quality of the salt and lack of DFS formulation standards and regulatory monitoring protocols.

CONCLUSIONS

DFS programs need to focus on 1) improved technology with better consumer acceptance and better performance when used with lower-quality salt; 2) elucidation and enforcement of DFS formulation quality standards, along with producer incentives; and 3) strong government backing at the policy level. DFS offers a unique opportunity to leverage an almost universally consumed product with the addition of 2 important nutrients missing in many populations. However, program "maturity" will take time with urgent attention needed for quality production.