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Food fortification Debate
Gary Klugman
A National Food Fortification Program is shortly to be implemented in
South Africa. Gary Klugman replies to issues raised in the article by the Micronutrient
Initiative Advisors, based on their comments to the article published by
Science In Africa (January 2002), "
Addressing Malnutrition In South Africa ".
" In The Meantime, Fortification Delayed Means
Nutrition Denied "
This would be true if the fortification projected would result in
unquestionable benefit for the population and to ensure control of their
nutrient deficiencies. But, as the proposed fortification program is currently
presented, this is not the case. The core of the argument is based precisely in
the belief, that fortifying a staple food with the recommended compounds, that
have never been demonstrated in maize flour, to be effective in addressing the
known nutrient deficiencies, is meaningless, ineffective and misleading.
Quality Of Foods
The argument of quality of food becomes important only when enough food is
ingested. The Micronutrient Initiative Advisors, have contradicted their own
recommendations for nutrient dosage values to be added to maize flour, as they
concur, that in particular, the poor children of South Africa, rely almost
exclusively on maize porridge for their nutritional needs, and the
disproportionate dependency on maize, hence, if the problem of a population is
lack of food, to talk about quality is superfluous. In addition the
Micronutrient Initiative Advisors point out the high consumption of maize flour,
that is almost pure starch and contributes very little in terms of nutrients
being only a source of energy. With this extremely poor diet, a fortification
program has to focus on providing all the needed nutrients and in the needed
amounts to cover the nutritional daily requirements of the population, and not
only to add a small amount of nutrients, that does not make the diet
nutritionally sufficient, but only marginally better?. The definition of a food
fortification program is as follows; Fortification means the addition of one or
more nutrients to a food whether or not it is normally contained in the food for
the purpose of preventing or correcting a demonstrated deficiency of one or more
nutrients in the population or specific population groups by the relevant
authority (1).
Restoration of Minerals and Vitamins lost in processing
Maize flour is prepared by refining process, and the majority of the maize
flour consumed is de-germed. The germ contains the proteins and the balance is
almost pure starch. In a nutrient deficient population, to only restore the lost
mineral and vitamin values from processing and refining of maize, (mainly white
maize in South Africa) does not contribute significantly to the improvement of
the nutrient deficient sector of the population, hence they will remain
deficient. Maize flour IS NOT sufficient to make a population nutritionally
healthy.
Can Vitamin A RDA Be Achieved
According to the National Food Consumption Survey, there is a deficient
intake of vitamin A, and the fortification program had to be designed to fill
the void in relation to the mean need of vitamin A intake of the population
(RDA). According to Table 1, of the Micronutrient Initiative reply, 6.4 I.U.s'
of vitamin A per gram of dry maize flour is added and they assume, contrary to
their own data, that there is a final activity of vitamin A in the reconstituted
porridge of 60% of the added dose.
The argument, that 47% of the R.D.A. for children 1 - 3 years old is provided
in the fortified porridge, only has meaning if that amount is enough to cover
the daily need of the vitamin A, plus a significant extra amount to fill the
deficit. Thus in this case to state that via the proposed fortification process,
47% of the R.D.A. is been added, does not have any meaning.
Because there is a vitamin A deficiency, because one would like to correct the
deficiency, because there is a daily need of the vitamin A, that has to be
ingested, because the fortification level has to include the daily need, plus
the amount needed to correct the deficiency, to state that the proposed program
covers 47% of the R.D.A. does not have the significance that the Micronutrient
Initiative Advisors wish to imply. The fortified food should ensure, that the
daily intake of vitamin A of the population is sufficient to fulfill all needs.
If not, the measure would be a simple ineffective palliative, but not a solution
to the problem.
Since vitamin A will be added to cereal flours, that are also fortified with
reduced iron (of any kind), where is the data that shows that vitamin A is
stable in the presence of iron particles? Available literature shows that in the
presence of inorganic iron the stability of vitamin A is drastically reduced
(2).
The Micronutrient Initiative Advisors state that there is a projected
improvement of vitamin A status of South African children, this is wrong,
immoral and misleading. Where is the scientifically supported and published
evidence? Where in the world has such a program using the same recommended
compounds been proven to be successful?
Have the Micronutrient Initiative Advisors taken in to account that vitamin A is
process dependent and that the reconstitution of maize flour to porridge can
vary from 20 minutes to ± 3 hours of cooking on extreme heat, depending on the
custom of the population?
Thus the 40% vitamin A losses advocated is not based on any scientific
evaluations and industry is condemned to pay for these mistakes (experiments
carried out at the CSIR, Division Of Food Science And Technology, showed losses
of vitamin A when maize porridge was cooked for 25 minutes to be in the order of
97 - 100%, these results were deemed to be flawed and have not been used for the
design of the proposed national food fortification program).
The authors in addition state " The fortified maize will go a long way
to achieve vitamin A sufficiency, especially when combined with vitamin A from
other sources? ", and yet the same authors are unanimous in their
conclusions, " That many South African children, particularly the poor,
rely almost exclusively on maize porridge for their nutrition? ". A vast
majority of the South African population can not afford the luxury of dietary
diversification.
Selection of Iron
Inert elemental iron powders are often collectively referred to as "
Reduced Iron " and are widely used as fortificants in cereal flours. These
iron powders however, are manufactured by 5 different processes, of which
electrolytic, is one manufacturing process.
Most people have now come to realize, that the reduced iron, traditionally used
to fortify cereal flours is not absorbed, (3) on the other hand for the proposed
national fortification program in South Africa, the Micronutrient Initiative
Advisors, recommendation is " ELECTROLYTIC REDUCED IRON ", and the
authors claim to have obtained a good absorption, but the information they
quote, Table 2, does not include maize flour, and that is the subject of this
discussion. The information the authors quote refers to the supposed use of
electrolytic iron in, wheat/milk cereal, wheat bread, plus ascorbic acid
(ascorbic acid is a promoter of iron and is not recommended in the proposed
National Food Fortification Program) but, there is absolutely no mention on
tests conducted on maize flour. The original publications could not be found and
it would be interesting to note what procedure was used to develop a radioactive
label of the electrolytic iron, and if the authors have any proof whatsoever,
that the process does not change the characteristics of the iron particles (it
would be appreciated if the authors could advance copies of these publications).
If the electrolytic iron is absorbed 50% of the absorption of Ferrous
Sulphate, then the figures presented do not show this relationship.
There are a number of issues that have to be answered and not only avoided. For
example, what IS the actual absorption of electrolytic iron of a defined
particle size in maize porridge? Where have the results of the investigations
been published? How many countries have tested and corroborated that the iron
particles are indeed absorbed? Where is the data that shows that the absorption
of electrolytic iron is regulated by the iron reserves of the body, to avoid any
possibility of iron overload? Where are the publications showing in an
unquestionable manner, that the use of electrolytic reduced iron (or any other
reduced iron) has resulted in the control of Iron Deficiency and Iron Deficiency
Anaemia in any country in the world? Where is the data proving that electrolytic
reduced iron is better absorbed than other reduced iron compounds of the same
particle size? All these questions have to be answered by the Micronutrient
Initiative Advisors, insisting on the use of iron particles for flour
fortification in South Africa.
Bioavailability of Electrolytic Iron
The Micronutrient Initiative Advisors, in their reply, try and explain the
poor absorption of electrolytic reduced iron with the argument of the small
amount of absorbed iron that is needed daily, (4) but this argument again is at
fault because it is misleading. For example the < 2% absorption of Ferrous
Sulphate in maize porridge as reported by Bovell - Benjamin et. al (5) and if
the calculations as suggested could really be applied, that would imply
absorption of the electrolytic reduced iron of only 2 x 0.5 = 1%, which is very
poor, and a serving size of 200g dry maize flour contains 7.4mg Fe (for the sake
of this calculation we will accept that the 7.4mg Fe is elemental) the amount of
absorbed electrolytic reduced iron upon consumption of 500g maize porridge, will
be 0.074mg Fe. Regardless, this is pure speculation, and again, it would be only
fair to insist on published scientific peer reviewed data on the true
bioavailability of electrolytic reduced iron, with a particle size of 45
micrometers in diameter, in a high phytate food, such as maize porridge, to be
provided by the Micronutrient Initiative Advisors to the South African public
and the South African Department of Health. Publications that support the poor
bioavailaility of Reduced Iron Compounds with a particle size of < 10
micrometers in diameter are (6) (7) (8) (9).
For the record, I stated in my article in Science In Africa (January
2002), that the reduced iron IS electrolyticaly manufactured and the South
African Department of Health have recommended that the particle size be 45
micrometers in diameter. (This is the only commercial grade electrolytic reduced
iron available in the market at a cost affordable price. If the particle size of
the electrolytic reduced iron is < 10 micrometers in diameter, industry could
not afford to utilize it as a fortificant, it is cost prohibitive, and all
studies carried out on reduced iron (6) (7) (8) (9), used particle sizes < 10
micrometers in diameter)
Fortification lessons to be borrowed from other countries
The quoted success in North and South America is not true. Where is the
published evidence for this? If any evidence does exist, did the investigators
use the same compounds of the same dosage levels and sizes as they propose to
use in South Africa? Have the Micronutrient Initiative Advisors any data on
metal to metal interactions? What is the bioavailability of ZnO?. Where is the
data showing that there is no mutual interference for absorption of these
metals? The available data indicates that interference occurs.
Vitamin A fortification in sugar is a huge success in addressing vitamin A
deficiency, Guatemala, El Salvador etc. Venezuela fortify wheat and maize flour
with Ferrous Fumarate, this resulted in a decline in ID/IDA and only use reduced
iron to top up the difference of elemental content as specified by local law.
Currently, in Central America, recognition is now been given to reconsider over
50 years of failure of iron fortification in cereal flours with reduced iron
compounds and more bioavailable iron compounds are being sought to address the
increase in ID/IDA, which is increasing beyond the population growth. (and it is
mandatory to fortify all cereal flours with iron in these countries).
In conclusion, it must be clearly stated that the nutritional needs of South
African children and their children to be, must not be handicapped through the
lack of delivery of a successful national food fortification program and all
parties concerned, that have a true desire to address poverty and malnutrition,
must embrace the knowledge that has been bestowed upon them, share information
and continuously exchange information on food and nutrition, borrow lessons
where we can and implement as many strategies possible and feasible, that will
allow South African and African children to take their rightful place in the
International Community.
Gary Klugman
E-mail
(W) 021 9102780
(C) 083 644 0355
Return to Article by Micronutrient Initiative Advisors
or read their reply
to this article:
REFERENCES
1) Document published by the Department Of Health, 22nd February 2002 "
Regulations Governing The Fortification Of Foodstuffs "
2) Bourdonnais A. Stabilite d' une solution de Vitamine A au cours du temps en
presence de Metalozate de fer. Zootech Technical Bull 1994.
3 ) Towards A Harmonization Criteria For The Fortification Of Wheat Flour In
Central America; Omar Dary, Ph.D INCAP/PAHO, November 10, 2001-12-09
4) Requirements of Vitamin A, Iron, Folate and Vitamin B12. Report of a joint
FAO/WHO Expert Consultation. FAO Food and nutrition Series No. 23 FAO Rome,
1988.
5) Bovell-Benjamin et.al Am J Clin Nutr 2000;71: 1563-69
6) Fomon S.J. Bioavailability of supplemental iron in commercially prepared dry
infant cereals. J Pediat 1987;110:660-61
7) Rios E. Hunter RE. Cook JD. Smith NJ. Finch CA. The absorption of iron as
supplement in infant cereal and infant formulas. Paediatrics 1975;55:686-93
8) Brise H. Hallberg L. Absorbability of different iron compounds. Acta Medica
Scand 1960;168(Suppl 358):2337
9) Hallberg L. Brune M. Rossander L. Low bioavailability of carbonyl iron in
man; Studies on iron fortification of wheat flour. Am J Clin Nutr 1986;43:59-67.
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