Micronutrient Deficiencies and Solutions

Introduction to Micronutrient Deficiencies

• Micronutrient deficiencies pose a major public health challenge globally, affecting both developing and developed nations
• The problem stands more pronounced in developing countries when compared to industrialized ones.
• Common micronutrient lacks in developing countries focus on iron, iodine, vitamin A, and zinc, particularly affecting women and children.
• Health consequences range from impaired brain development and poor pregnancy outcomes to weakened immunity, stunted growth, blindness, and even death
• Diets based on plant foods with limited or no animal sources increase the risk of such deficiencies in developing regions.
• Micronutrient deficiencies stunt economic growth.
• Strategies to combat include food fortification, biofortification, dietary diversification, and supplementation

Strategies for Improving Micronutrient Consumption

• Fortification involves adding nutrients to staple foods, infant foods, condiments, and processed foods.
• Biofortification enhances nutrient levels in crops through plant breeding, being effective for local food consumption in developing countries.
• Dietary diversification aids populations able to include animal source foods in their meals.
• Supplementation uses dietary supplements to prevent or treat deficiencies in at-risk groups like children and pregnant women.

Food Fortification Defined

• According to the Codex Alimentarius Commission (1987), fortification adds one or more essential nutrients to a food, whether normally contained or not
• The aim is preventing or correcting demonstrated nutrient deficiencies in populations or specific groups.
• Premixes containing measured micronutrients are added to foods during processing in national fortification programs.
• Fortification focuses on foods commonly eaten by the population and centrally processed for easy integration and consumer acceptance.
• Fortified foods include salt, cereals, fats, oils, and sugar.
• Key micronutrients added are vitamin A, vitamin D, folic acid, B-complex vitamins, iron, iodine, and zinc.

Types of Food Fortification

• Food fortification programs fit into mass, targeted, or market-driven approaches.

Mass Fortification (Large-Scale Food Fortification/LSFF)

• It involves adding micronutrients to widely consumed staples or condiments for the general population at public health risk for deficiencies.
• Micronutrients integrate during industrial processing into items such as salt, flours, oil, sugar, and condiments.
• LSFF programs entail mandatory government-regulated initiatives, such as fortified flour with folic acid, iodized salt, vitamin A fortified cooking oil, and vitamin A and D fortified milk.
• Food processors may also voluntarily fortify foods within regulatory limits.
• It can reach all population segments, including the most vulnerable.
• If uncontrolled, excess micronutrient consumption is possible in some populations.
• The cost of premix preparation poses a limitation in low and middle-income countries.

Targeted Fortification

• It refers to fortifying foods for specific groups like infants, young children, adolescents, pregnant women, and displaced people.
• It addresses a wide spectrum of micronutrients for specific at-risk populations.
• Complementary foods and infant formulas fall under targeted fortification, with regulated compositions and nutrient content.

Market Driven Fortification

• Fortifying manufactured foods offers marketing advantages and consumer benefits.
• Food processors leverage added nutrient content for marketing, adhering to nutrient regulations.
• Breakfast cereals and chocolate drink powders exemplify market-driven fortification.
• These products are often too expensive for most people in developing countries.

Selecting Fortification Vehicles

• Selecting suitable foods requires careful consideration for implementing food fortification programs.
• Dietary surveys to gauge micronutrient intake and consumption level of targeted foods will help in this process
• Food consumption variability within the population ensures safety and impact, considering high vs. low consumption.
• Foods considered as micronutrient carriers should be:
  • Commonly consumed by target populations
  • Present a constant consumption pattern and low risk of excess intake
  • Stable during storage
  • Relatively inexpensive
  • Centrally processed with minimal fortificant stratification
  • Have no interaction between fortificant and carrier
  • Be in most meals
  • Have availability independent of socioeconomic status
  • Linked to energy intake

Common Food Vehicles for Fortification

• Common food choices include:
  • Maize
  • Wheat and wheat products
  • Cooking oils
  • Milk and dairy
  • Sugar
  • Rice
  • Salt
  • Condiments

Biofortification

• It increases nutrient levels in crops during growth, unlike postharvest processing.
• Agronomic practices, plant breeding, and biotechnology can achieve this.
• It examples include:
  • Iron-biofortification of rice, beans, sweet potato, cassava, and legumes
  • Zinc-biofortification of wheat, rice, beans, sweet potato, and maize
  • Provitamin A carotenoid-biofortification of sweet potato, maize, and cassava

Point-of-Use Food Fortification

• It, or home fortification, entails adding vitamins and minerals to cooked, ready-to-eat food.
• 2016: WHO recommended fortifying complementary foods with micronutrient powders (MNPs) to boost micronutrient consumption and reduce anemia in children aged 6 to 24 months.
• Most countries use a 15 micronutrient MNP formula, providing one RNI per dose for children 6-59 months old

Wheat and Maize Flour Fortification

• Wheat and maize constitute the most vital food crops for humans globally, according to the FAO (2015).
• These are grown worldwide.
• Wheat flour yields pastas, breads, noodles, biscuits, and cakes.
• Corn is consumed as corn on the cob, in cornbread, drinks, and snack foods.
• 2009: WHO issued recommendations on wheat and maize flour fortification, adding iron, folate, vitamin B12, vitamin A, and zinc.
• 2016: WHO maize flour guidelines added thiamine, riboflavin, niacin, pyridoxine, and pantothenic acid to the 2009 list.
• Some countries mandate or encourage wheat and maize flour fortification.
• Rwanda published regulations in 2020 (Regulation No. CBD/TRG/003 Rev. No. 1), mandating fortification of wheat and maize flours.
• Flour fortification reduces neural tube defects (folic acid) and anemia (iron).

Rice Fortification Methods

• Several ways exist to enhance micronutrient content in rice:
  • Parboiling: This transfers micronutrients, such as vitamin B1, from bran to grain.
  • Breeding Techniques: Enhance micronutrients, like Zinc.
  • Dusting: Mix premixes.
  • Coating rice grains: Use liquid waxes containing fortificants.
  • Extrusion Technique: Integrate micronutrients by extruding rice flour combined with micronutrients and forming fortified rice-like grains, mixed with normal rice at 0.5–2% for target nutrient levels.

Factors for Rice Fortification and Consumer Acceptance

• Fortified rice is more accepted when it does not change the rice's appearance, smell, or flavor.
• Fortified rice should match the non-fortified rice's color and shape.
• Certain fortificants, like riboflavin (vitamin B2), beta-carotene, and some iron forms, cause discoloration and may thus be discarded.

Salt as a Nutrient Carrier

• Salt stands universally consumed irrespective of socio-economic status.
• It is used at both household and industrial levels.
• Salt centrally processes, so it makes an ideal vehicle for fortification.
• It, an essential mineral in humans and animals, aids thyroid function, as well as bone and brain development during fetal growth and infancy
• Daily iodine intake includes:
  • Birth to 6 months: 110 mcg
  • Infants 7-12 months: 130 mcg
  • Children 1-8 years: 90 mcg
  • Children 9-13 years: 120 mcg
  • Teens 14-18 years: 150 mcg
  • Adults: 150 mcg
  • Pregnant teens and women: 220 mcg
  • Breastfeeding teens and women: 290 mcg
• Iodine deficiency results in congenital abnormalities (cretinism), still-births, impaired brain development, low cognitive capacity, delayed sexual development, with goiter from thyroid enlargement.
• The Universal Salt Iodization (USI) program, launched by the UN in 1980, set out to eliminate iodine deficiency globally.
• All consumed salt integrates into the program, from household use to animal consumption.
• Potassium iodate adds iodine to salt after refining, and before drying and packing.
• Salt iodization uses either a wet method, adding potassium iodate solution, or a dry method, adding dry potassium iodate/iodide powder mixed with calcium carbonate/dry salt.

What are Condiments?

• Condiments are substances enhancing flavor when added to food in small quantities during preparation or consumption.
• Sugar and salt are primary condiments globally, basis for other condiments, improving flavor, safety, and storage quality.
• Condiments in food fortification:
  • Affordability and consistent, predictable use across socio-economic classes
  • Masking of undesirable changes through natural colors
  • Potential for micronutrient fortification in different countries
• Condiments also contribute to high salt and sugar intake, increasing the risk of NCDs (non-communicable diseases).
• Nutrition policies must balance limiting salt/sugar alongside adequate micronutrient intake from fortification through condiments.

Condiment Forms

• Physical form influences fortification technology.
• Solid: Sugar, salt, mustard, pepper, powders
• Semisolid: Tomato paste, mayonnaise, chutney
• Liquid: Vinegar, soy sauce, chili oil
• Single ingredient or mixture of ingredients

Challenges of Food Condiment Fortification

• Condiments require high micronutrient doses due to small serving sizes, affecting sensory traits and shelf life.
• High sugar/salt in condiments impacts flavoring purposes
• High consumption of salt/sugar from condiments links to increased NCDs risks.

What are Bouillon Cubes?

• They're seasoning made of kitchen salt (40-70%), hydrolyzed vegetable proteins, vegetable fat, herbs, starch, flavorings, and spices.
• Private companies voluntarily fortify these products through market-driven fortification.
• Prevalently used in Western and Central Africa, this low cost is only of limited use.
• They prove good vehicles for micronutrient fortification.

Bouillon Cubes and Food Fortification

• Bouillon cubes are fortified with iodine and iron.
• Iodized salt results in iodine addition through the indirect fortification method.
• Iodine from cubes contributes to iodine requirements, depending on intake levels and iodine content.
• Iron integrates through ferric pyrophosphate (FPP).
• This iron type faces issues with organoleptic properties, low water solubility, and low absorption rates.
• Ongoing research aims to enhance iron bioavailability via sodium pyrophosphate (NaPP) to make soluble complexes with FPP.

Edible oils

• Fats and oils offer energy, plus fat-soluble vitamin transport and absorption
• It boosts food flavor and palatability while reducing hunger sensations.
• Oil-based diets are low in essential nutrients, especially in some communities
• Vitamin A deficiency prevails in developing countries, with Vitamin D concerns throughout Nordic regions with minimal sunlight.
• Animal fats like butter and lard contain A, however, vegetable oils do not, though unrefined oils yield beta carotene (precursor to A).
• Red palm oil harbors both beta and alpha carotene (2.4 mg and 1.8 mg per 10g, respectively)
• Palm oil is metabolized in the human body.
• Red palm oil's intense color limits applications due to its color.
• Fats and oils are expensive and only of limited use in developing countries.

Rationale for Edible Oil Fortification

• Technical feasibility:
  • Vegetable oils serve as practical agents for fortification via fat soluble Vitamins A, D, E, and K since manufacturers refine oils on the central system.
  • Vitamins blend effectively, minimizing the need for more sophisticated specialized equipment
  • Vitamin A does not alter taste, color, or shelf-life in low volumes.
  • Vitamin A is stable during frying.
  • Specialized packaging stops UV rays from impeding Vitamin A effectiveness.
• Human consumption:
  • Vegetable oils serve to benefit the wide range of communities due to their wide accessibility
  • Regular use amongst these populations
• Domestic production:
  • Responding to Government directives, local oil producers are generally receptive to fortification quality controls.
• Industry concentration:
  • Centralized production of the oil milling industry limits small-scale community outputs.
  • The process ultimately eases fortification.

Factors on Fortification

• Low incremental cost:
  • A mere 0.1%-0.3% rise in fortification costs with Vitamin A keeps prices affordable
  • Easy implementation with limited additional procedures/tasks.
• Cost-effectiveness:
  • Easy and stable mixture through use of concentrated additions, while the cost of necessary equipment is low.
• Technological aspects:
  • 45-50°C: appropriate vitamin A and D concentrate temperatures for specified oil.
  • Enhanced solubility of Vitamin A+D
  • Mixture prevention from oils via additives like Vitamin E
• Quality Control is maintained through precise mixing and UV protection
• To prevent damage during distribution be sure to avoid:
  • Extended Agitation: This will cause an addition of more air and raise risks of oxidation
  • Direct Light: Pack and storing properly after fortification will help avoid sun damage.