https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(10)62304-5.pdf

Anaemia in low-income and middle-income countries

Iron bioavailability and dietary reference values

The Biomarkers of Nutrition for Development (BOND) project is designed to provide evidence-based advice to anyone with an interest in the role of nutrition in health. Specifically, the BOND program provides state-of-the-art information and service with regard to selection, use, and interpretation of biomarkers of nutrient exposure, status, function, and effect. To accomplish this objective, expert panels are recruited to evaluate the literature and to draft comprehensive reports on the current state of the art with regard to specific nutrient biology and available biomarkers for assessing nutrients in body tissues at the individual and population level. Phase I of the BOND project includes the evaluation of biomarkers for 6 nutrients: iodine, iron, zinc, folate, vitamin A, and vitamin B-12. This review represents the second in the series of reviews and covers all relevant aspects of folate biology and biomarkers. The article is organized to provide the reader with a full appreciation of folate's history as a public health issue, its biology, and an overview of available biomarkers (serum folate, RBC folate, and plasma homocysteine concentrations) and their interpretation across a range of clinical and population-based uses. The article also includes a list of priority research needs for advancing the area of folate biomarkers related to nutritional health status and development.

/pdf/biomarkers-of-nutrition-for-development-bond-iron-review-4ibc6okj7y.pdf

Biomarkers of Nutrition for Development (BOND)-Iron Review.

Zinc (Zn) still represents an important health problem in developing countries, caused mainly by inadequate dietary intake. A large consumption of cereal-based foods with small concentrations and low bioavailability of Zn is the major reason behind this problem. Modern cultivars of cereals have inherently very small concentrations of Zn and cannot meet the human need for Zn. Today, up to 50% of wheat-cultivated soil globally is considered poor in bioavailable Zn. Agricultural strategies that are used to improve the nutritional value of crop plants are known as biofortification strategies. They include genetic biofortification, which is based on classical plant breeding and genetic engineering for larger nutrient concentrations, and greater agronomic biofortification, which is based on optimized fertilizer applications. This review focuses on agronomic biofortification with Zn, which has proved to be very effective for wheat and also other cereal crops including rice. Molecular and genetic research into Zn uptake, transport and grain deposition in cereals are critically important for identifying ‘bottlenecks’ in the biofortification of food crops with Zn. Transgenic plants with large Zn concentrations in seeds are often tested under controlled laboratory or glasshouse conditions with sufficient available Zn in the growth medium for the entire growth period. However, they might not always show the same performance under ‘real-world’ conditions with limited chemical availability of Zn and various stress factors such as drought. What purpose can an upgraded transport and storage system serve if the amount of goods to be transported and stored is limited anyway? Given the fact that the Zn concentrations required to achieve a measurable impact on human health are well above those required to avoid any loss of yield from Zn deficiency, providing crop plants with sufficient Zn through the soil and foliar fertilizer strategy under field conditions is critically important for biofortification efforts.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/ejss.12437

Agronomic biofortification of cereals with zinc: a review

Background
Vitamin A deficiency (VAD) is a major public health problem in low- and middle-income countries, affecting 190 million children under five years of age and leading to many adverse health consequences, including death. Based on prior evidence and a previous version of this review, the World Health Organization has continued to recommend vitamin A supplementation for children aged 6 to 59 months. There are new data available from recently published randomised trials since the previous publication of this review in 2010, and this update incorporates this information and reviews the evidence.

Objectives
To assess the effects of vitamin A supplementation (VAS) for preventing morbidity and mortality in children aged six months to five years.

Search methods
In March 2016 we searched CENTRAL, Ovid MEDLINE, Embase, six other databases, and two trials registers. We also checked reference lists and contacted relevant organisations and researchers to identify additional studies.

Selection criteria
Randomised controlled trials (RCTs) and cluster-RCTs evaluating the effect of synthetic VAS in children aged six months to five years living in the community. We excluded studies involving children in hospital and children with disease or infection. We also excluded studies evaluating the effects of food fortification, consumption of vitamin A rich foods, or beta-carotene supplementation.

Data collection and analysis
For this update, two reviewers independently assessed studies for inclusion and abstracted data, resolving discrepancies by discussion. We performed meta-analyses for outcomes, including all-cause and cause-specific mortality, disease, vision, and side effects. We used the GRADE approach to assess the quality of the evidence.

Main results
We identified 47 studies (4 of which are new to this review), involving approximately 1,223,856 children. Studies took place in 19 countries: 30 (63%) in Asia, 16 of these in India; 8 (17%) in Africa; 7 (15%) in Latin America, and 2 (4%) in Australia. About one-third of the studies were in urban/periurban settings, and half were in rural settings; the remaining studies did not clearly report settings. Most of the studies included equal numbers of girls and boys and lasted about a year. The included studies were at variable overall risk of bias; however, evidence for the primary outcome was at low risk of bias. A meta-analysis for all-cause mortality included 19 trials (1,202,382 children). At longest follow-up, there was a 12% observed reduction in the risk of all-cause mortality for vitamin A compared with control using a fixed-effect model (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.83 to 0.93; high-quality evidence). This result was sensitive to choice of model, and a random-effects meta-analysis showed a different summary estimate (24% reduction: RR 0.76, 95% CI 0.66 to 0.88); however, the confidence intervals overlapped with that of the fixed-effect model. Nine trials reported mortality due to diarrhoea and showed a 12% overall reduction for VAS (RR 0.88, 95% CI 0.79 to 0.98; 1,098,538 participants; high-quality evidence). There was no significant effect for VAS on mortality due to measles, respiratory disease, and meningitis. VAS reduced incidence of diarrhoea (RR 0.85, 95% CI 0.82 to 0.87; 15 studies; 77,946 participants; low-quality evidence) and measles (RR 0.50, 95% CI 0.37 to 0.67; 6 studies; 19,566 participants; moderate-quality evidence). However, there was no significant effect on incidence of respiratory disease or hospitalisations due to diarrhoea or pneumonia. There was an increased risk of vomiting within the first 48 hours of VAS (RR 1.97, 95% CI 1.44 to 2.69; 4 studies; 10,541 participants; moderate-quality evidence).

Authors' conclusions
Vitamin A supplementation is associated with a clinically meaningful reduction in morbidity and mortality in children. Therefore, we suggest maintaining the policy of universal supplementation for children under five years of age in populations at risk of VAD. Further placebo-controlled trials of VAS in children between six months and five years of age would not change the conclusions of this review, although studies that compare different doses and delivery mechanisms are needed. In populations with documented vitamin A deficiency, it would be unethical to conduct placebo-controlled trials.

/pdf/vitamin-a-supplementation-for-preventing-morbidity-and-33kmuv59qa.pdf

Vitamin A supplementation for preventing morbidity and mortality in children from 6 months to 5 years of age.

BackgroundIron fortification of wheat flour is widely used as a strategy to combat iron deficiency.ObjectiveTo review recent efficacy studies and update the guidelines for the iron fortification of...

https://journals.sagepub.com/doi/pdf/10.1177/15648265100311S102

Revised recommendations for iron fortification of wheat flour and an evaluation of the expected impact of current national wheat flour fortification programs

BackgroundZinc fortification is recommended as an appropriate strategy to enhance population zinc status, but guidelines are needed on the appropriate types and levels of zinc fortification of cere...

https://journals.sagepub.com/doi/pdf/10.1177/15648265100311S106

Zinc fortification of cereal flours: current recommendations and research needs.

General fortification of cereal staples, such as wheat flour and maize meal, has proven to be a cost-effective method to reduce micronutrient deficiencies. Recent recognition of the problem of zinc deficiency has led to its being included in newly started cereal-enrichment programs in Indonesia and Mexico and in a cereal-fortification program being proposed for South Africa. The amount of zinc added in these programs is 20 to 30 ppm. Zinc oxide is currently the preferred source because it has the lowest cost and produces less flavor change than zinc acetate and zinc sulfate. This article reviews the use of different zinc salts as fortificants, considering their possible effects on product quality and bioavailability, recommended levels of fortification with estimated effects on zinc consumption, and current fortification programs with cost estimates.

Zinc enrichment of cereal staples.

Zinc enrichment of cereal staples

Background: Vitamin A deficiency is a major public health nutrition problem, affecting an estimated 190 million preschool-aged children and 19 million pregnant and lactating women globally, and 83 million adolescents in Southeast Asia alone Its consequences (disorders) include xerophthalmia (the leading cause of early childhood blindness), increased severity of infection, anemia, and death Because vitamin A deficiency is largely due to chronic dietary insufficiency of preformed vitamin A and proactive carotenoids, food fortification can offer an effective approach to prevention Objective : To provide guidance on fortifying wheat and maize flour milled in industrial rollers for national fortification programs in countries where vitamin A deficiency is considered a public health problem Methods: Critical review of the literature on the dietary gap in vitamin A intake and levels of wheat flour intake among risk groups as a basis for determining vitamin A fortificant levels Additional review of efficacy evidence, safety and cost considerations, and country experiences related to wheat-flour fortification with vitamin A Results: Mill-rolled wheat flour is a technically fortifiable, centrally processed food vehicle that, where routinely and adequately consumed by target groups, should be considered a candidate for fortification Vitamin A can be stable in flour under typical, ambient conditions, with processing losses estimated at approximately 30%, depending on source and premix conditions Conclusions : Factors to guide a decision to fortify flour with vitamin A include the extent of deficiency, availability of other food vehicle options, the centrality of milling, market reach and population intake distributions of the flour products, the dietary vitamin A intake required, and associated costs Large gaps persist in knowledge of these factors, which are needed to enable evidence-based fortification in most countries, leaving most decisions to fortify guided by assumptions Where flour can and should be fortified, guidelines are given for providing nearly 25% of the Recommended Dietary Allowance for vitamin A to vulnerable groups consuming varying ranges of flour products The costs will vary according to the level of fortification

http://www.a2zproject.org/~a2zorg/pdf/Vitamin%20A%20fortification%20of%20wheat%20flour%20Considerations%20and%20current%20recommendations.pdf

Vitamin A fortification of wheat flour: considerations and current recommendations

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