Changes in polyunsaturated fatty acids during treatment of malnourished children may be insufficient to reach required essential fatty acid levels - A randomised controlled trial.

BACKGROUND & AIMS: Severe acute malnutrition (SAM) is a global concern. Studies on the impact of ready-to-use therapeutic foods (RUTFs) on polyunsaturated fatty acids (PUFA) are almost non-existent. The aim was to investigate the change in whole-blood PUFA and nutrition and health markers among Cambodian children with SAM after treatment with RUTFs. METHODS: The trial was an 8-week randomised clinical trial of the effectiveness of locally produced fish-based RUTF (L-RUTF) vs standard milk-based RUFT (S-RUTF). Whole-blood fatty acids were analysed using dried blood spots. Nutrition and health markers were assessed using anthropometric assessment and blood samples for markers of inflammation. The trial was conducted at the National Pediatric Hospital, Phnom Penh, Cambodia, with one hundred and twenty-one 6-59-month-old children in treatment for SAM. RESULTS: L-RUTF had a higher content of n-3 PUFA and a higher content of arachidonic acid (AA) and docosahexaenoic acid (DHA), while S-RUTF had the highest content of n-6 PUFA. At baseline, the children presented with a Mead acid level in whole-blood of around 0.08% of total fatty acids (FA%) and an omega-3 index of ∼0.91 ± 0.44. After eight weeks of S-RUTF treatment, linoleic acid (LA), AA, n-6/n-3 PUFA ratio, and Mead acid levels were increased. The L-RUTF intervention did not change the whole-blood PUFAs from baseline. At discharge, the children in the L-RUTF group had a lower n-6/n-3 PUFA ratio than the children in the S-RUTF group, driven by a lower alpha-linolenic acid (ALA) (0.20 vs 0.27 FA%, p = 0.004) and lower LA (15.77 vs 14.21 FA%, p = 0.018) with no significant differences in AA or DHA levels. Weight-for-height z-score at discharge was negatively associated with total PUFA (ß -1.4 FA%, 95%CI. -2.7; -0.1), n-6 LCPUFA (ß -1.3 FA%, 95%CI. -1.3; -0.3), and AA (ß -0.6 FA%, 95%CI. -1.0; -0.2). Age-adjusted height was negatively associated with the Mead acid:AA ratio (ß -1.2 FA%, 95%CI. -2.2; -0.2). No significant change was seen in inflammation markers within groups or between groups during treatment, and n-3 and n-6 PUFAs were not associated with markers of inflammation or haemoglobin status at discharge. CONCLUSION: The trial found that whole-blood markers of PUFA status were low in children at admission and discharge from SAM treatment, indicating that the currently recommended composition of RUTFs are not able to correct their compromised essential fatty acid status. The higher content of DHA and AA in L-RUTF did not give rise to any improvement in PUFA status. No changes in health markers or associations between PUFA and health markers were found. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02907424.

The Association between Iron and Folic Acid Supplementation and Malaria Prophylaxis and Linear Growth among Children and Neonatal Mortality in Sub-Saharan Africa-A Pooled Analysis.

The majority of research on linear growth among children is confined to South Asia and focuses on iron and folic acid (IFA) supplementation during pregnancy, without considering malaria prophylaxis. Similarly, there is limited evidence on the association of antenatal IFA supplementation and malaria prophylaxis with neonatal mortality in sub-Saharan Africa (SSA). This study aims to address these gaps. A pooled analysis of demographic and health survey (DHS) data from 19 countries in SSA was conducted to study the association between IFA supplementation and malaria prophylaxis and linear growth and neonatal mortality. Multivariate logistic and linear regression models were used. Malaria prophylaxis was significantly associated with stunting, height-for-age Z scores (HAZ scores), and neonatal mortality, but IFA supplementation was not associated with these outcomes. When women's height and body mass index (BMI) were introduced in the model, a significant association between combined malaria prophylaxis and IFA supplementation was found with HAZ scores only. For severe stunting, no significant association was found with either in the two models. In conclusion, this study underscores the importance of antenatal malaria prophylaxis as a potential intervention for nutrition outcomes (linear growth) and neonatal mortality, as well as the importance of coordinating efforts between malaria and the health and nutrition sectors to improve these outcomes in the countries of SSA.

Estimates of child mortality reductions attributed to vitamin A supplementation in sub-Saharan Africa: scale up, scale back, or refocus?

BACKGROUND: Vitamin A supplementation (VAS) has been implemented in over 82 countries globally, primarily because of its beneficial effect in preventing child mortality. Secular reductions in child mortality and the implementation of alternative programs to promote vitamin A intake have led to questions on the need for national VAS programs. OBJECTIVES: This study aimed to estimate child mortality changes related to VAS using current, scale-back, and scale-up coverage scenarios. METHODS: Data related to demographic characteristics, fertility, intervention coverage, anthropometry, child mortality and cause-of-death structure were integrated into the Lives Saved Tool (LiST). We estimated the cause-specific (LiST model) and all-cause mortality reductions related to VAS based on evidence from recent meta-analyses. RESULTS: Between 2008 and 2018, VAS coverage declined in most sub-Saharan African (SSA) countries. In 2019 alone, 12% and 24% reductions in all-cause mortality related to VAS were expected to avert from 105,332 to 234,704 child deaths, respectively, in SSA; whereas the cause-specific mortality model (LiST) estimated that 141,670 child deaths were averted in 2019. Estimates of VAS-related child mortality reductions were highly variable among countries. Our scaling-back scenario led to highly variable country-level results, with expected increases in mortality rates, from a low of 0.04/1000 live births to as high as 49.3/1000 live births, suggesting that some countries could start considering scaling back, while others need to scale up. CONCLUSIONS: Excess child mortality that would be preventable by VAS has declined, but is still significant in many SSA countries. While scale-up of VAS is needed for most of the countries, scaling back can also be considered in some countries. Policy decisions, however, should be guided by more recent data on food consumption, vitamin A statuses, child health, and vitamin A fortification coverage.

Evaluating the coverage and quality of nutrition programs via a bottom-up approach: A secondary analysis of real-time data from an end-user monitoring system in Ethiopia.

Over the last two decades, great efforts and investments have been made in Ethiopia to ensure that all children have equal access to nutrition services in health facilities. While quality health systems are a prerequisite for quality nutrition services, little attention has been given to the evaluation of the supply and delivery services. The purpose of the study was to evaluate the coverage and quality of the nutrition-specific interventions delivered through the health system. Using an end-user monitoring (EUM) system, we monitored the delivery of nutrition-specific interventions in 500 districts, having 2514 health facilities distributed throughout Ethiopia. Data were collected through third-party monitors between August 2020 and 2021. Roughly 90% of health facilities were performing severe acute malnutrition management in line with the national guideline/protocol, and 2/3 of the assessed facilities were delivering iron and folic acid, vitamin A supplementation and deworming. A third of the messages on AMIYCN were retained by beneficiaries. Warehouse conditions were good in 64.3% of the facilities, but only 22% had good recording practices and about half had problems related to the quality and availability of nutrition supplies. Most beneficiaries were satisfied with the nutrition supplies and service delivered at the health facility level. This study also suggests the relevance of an EUM system to assess the quality of nutrition service delivery and its related supply management, as well as to improve the implementation of nutrition interventions as a decision-making tool.

Vitamin A supplementation and estimated number of averted child deaths in Ethiopia: 15 years in practice (2005-2019).

Vitamin A supplementation (VAS), started as a short-term strategy pending dietary improvements, has been implemented in Ethiopia for the last 15 years. We aimed to describe the trends in VAS coverage and estimated the associated reductions in child mortality. VAS coverage data obtained from the District Health Information System and the Demographic and Health Surveys were linked to child mortality data from the United Nations Interagency Group for Child Mortality Estimation (UN IGME). The number of child deaths averted was modelled assuming 12% and 24% reductions in all-cause mortality. From 2006 to 2011, VAS was delivered through campaigns, and coverage was above 85%. However, from 2011 onwards, VAS delivery was integrated to the routine health system, and the coverage declined to <60% with significant disparities by wealth quintile and rural-urban residence. VAS has saved between 167,563 to 376,030 child lives (2005-2019), but additional lives (>42,000) could have been saved with a universal coverage (95%). Inconsistent supply of vitamin A capsules, but more importantly, low access to health care, and the limited contact opportunities for children after 24 months may have contributed to the declining VAS coverage. Any changes in target or scale-up should thus consider these spatial and socioeconomic variations. Increasing the coverage of VAS and closing the equity gap in access to nutrition services is critical. However, with alternative programmes like vitamin A fortification being set-up, the benefits and safety of VAS need to be closely monitored, particularly in areas where there will be overlap.

Whole-blood PUFA and associations with markers of nutritional and health status in acutely malnourished children in Cambodia.

OBJECTIVE: To measure fatty acid composition, particularly whole-blood PUFA content, in acutely malnourished children and identify associations with markers of nutritional and health status. DESIGN: PUFA were assessed in dried blood spots obtained from a cross-sectional study. Nutritional and health status were assessed by anthropometry, haemoglobinopathies, inflammation and blood counts. SETTING: Cambodia. PARTICIPANTS: The study was conducted with 174 children aged 0·5-18 years with acute malnutrition. RESULTS: Among total fatty acids (FA), the relative percentage of total PUFA was 20 % FA, with 14 % of the children having very low PUFA (mead acid (MA):arachidonic acid (AA) >0·02, n-6 docosapentaenoic acid:DHA >0·2 and total n-6:n-3 PUFA >10·5). Wasting was not associated with any PUFA. Stunting and low height were consistently positively associated with total PUFA and positively with n-6 PUFA. Height was positively associated with n-3 long-chain PUFA (LCPUFA). The presence of haemoglobinopathies or inflammation was positively associated with MA:AA, but not total PUFA. Elevated blood platelet counts were positively correlated with linoleic acid and appeared to be influenced by anaemia (P = 0·010) and inflammation (P = 0·002). Monocyte counts were high during inflammation (P = 0·052) and correlated positively with n-6 LCPUFA and n-3 LCPUFA. CONCLUSIONS: Children with acute malnutrition or stunting had low PUFA, while elevated platelets and monocytes were associated with high PUFA. In acutely malnourished children, inflammation could lead to elevated blood cell counts resulting in increased whole-blood PUFA which does not reflect dietary intake or nutritional status.

Effectiveness of a locally produced ready-to-use supplementary food in preventing growth faltering for children under 2 years in Cambodia: a cluster randomised controlled trial.

This cluster randomised controlled trial tested the effectiveness of a locally produced, fish-based, ready-to-use supplementary food (RUSF) to prevent growth faltering (decline in z-scores). Cambodian infants (n= 485), aged 6 to 11 months, were randomised by site to receive the RUSF, Corn-Soy Blend++ (CSB++), micronutrient powders (MNP), or no supplement (control). The intervention was for 6 months. In unadjusted analysis, the control group had statistically significantly decreased weight-for-age z-scores (WAZ; -0.02, 95%CI = -0.03 - -0.01, P= 0.001) and height-for-age z-scores (HAZ; -0.07, 95%CI = -0.09 - -0.05, P < 0.001), and increased mid-upper arm-circumference (MUAC; 0.02cm, 95%CI = 0.01 - 0.04, P = 0.010), but no statistically significant change in weight-for-height z-scores (WHZ). The RUSF group did not differ significantly from the control for WAZ, HAZ or WHZ (in other words, WAZ and HAZ decreased and WHZ did not change), but had increased MUAC in comparison to the control (0.04cm, 95%CI = 0.01 - 0.06, P = 0.008). There were no statistically significant differences between the RUSF group and the CSB++ or MNP groups with respect to WAZ, HAZ, WHZ or MUAC. Interestingly, in adjusted analysis, low consumers of RUSF had increased WAZ, WHZ and MUAC (0.03, 95%CI = 0.01-0.06, P = 0.006; 0.04, 95%CI = 0.01-0.08, P = 0.026; and 0.05cm, 95%CI = 0.02-0.09, P = 0.004, respectively) compared with the control. The novel RUSF, particularly in small quantities, protected against ponderal growth faltering, but the improvements were of limited clinical significance.

Development and testing of locally-produced ready-to-use therapeutic and supplementary foods (RUTFs and RUSFs) in Cambodia: lessons learned.

BACKGROUND: Rates of childhood undernutrition are persistently high in Cambodia. Existing ready-to-use supplementary and therapeutic foods (RUSFs and RUTFs) have had limited acceptance and effectiveness. Therefore, our project developed and trialled a locally-produced, multiple micronutrient fortified lipid-based nutrient supplement (LNS) with therapeutic and supplementary versions. This ready-to-use food (RUF) is innovative in that, unlike many RUFs, it contains fish instead of milk. Development began in 2013 and the RUF was finalised in 2015. From 2015 until the present, both the RUTF and the RUSF versions were trialled for acceptability and effectiveness. METHODS: This paper draws on project implementation records and semi-structured interviews to describe the partnership between the Cambodian Ministries of Health and Agriculture, Forestry and Fisheries, UNICEF, the French National Research Institute for Sustainable Development (IRD), universities, and Vissot factory. It discusses the project implementation and lessons learned from the development and trialling process, and insights into positioning nutrition on the health agenda in low and middle-income countries. RESULTS: The lessons learned relate to the importance of project planning, management, and documentation in order to seize opportunities in the research, policy, advocacy, and programming environment while ensuring adequate day-to-day project administration and resourcing. CONCLUSIONS: We conclude that projects such as ours, that collaborate to develop and test novel, locally-produced RUTFs and RUSFs, offer an exciting opportunity to respond to both local programmatic and broader research needs.

Acceptability of locally-produced Ready-to-Use Supplementary Food (RUSF) for children under two years in Cambodia: A cluster randomised trial.

In Cambodia, existing food products for treating or preventing undernutrition have met with limited success. Therefore, in 2014, alternative ready-to-use foods were developed. This trial aimed to assess the acceptability of the novel ready-to-use supplementary food (RUSF) as a snack or mixed with borbor (white rice porridge), compared with corn-soy blend plus plus (CSB++) and borbor fortified with micronutrient powder (MNP). The nonblinded, randomised 4 × 4 crossover trial recruited 95 children aged 9-23 months from communities in peri-urban Phnom Penh. Small quantities (100 g for porridges, 42 g for snack) of each food were offered for three consecutive days at testing sites (homes of health volunteers). Main outcomes were children's consumption, caregivers' assessment of children's preferences, and caregivers' ranking of the foods. Median percentage consumed of the test food servings ranged from 21 to 50% (p = 0.003). The odds of children consuming over 50% were greatest for borbor fortified with MNP versus RUSF snack (unadjusted OR = 6.79, CI = 2.80-16.47, p < 0.001). However, the median energy children received when consuming the RUSF with borbor (57 kcals) or as a snack (48 kcals) was greater than with CSB++ (15 kcals) or borbor fortified with MNP (18 kcals; p < 0.001). Therefore, although children ate less RUSF, it provided approximately three times more kilocalories. Caregivers reported that their children had the highest preference for borbor fortified with MNP. Caregivers themselves ranked the novel RUSF snack highest. Thus, the innovative RUSF was considered sufficiently acceptable to proceed to an effectiveness trial.

Randomised controlled trial to test the effectiveness of a locally-produced ready-to-use supplementary food (RUSF) in preventing growth faltering and improving micronutrient status for children under two years in Cambodia: a study protocol.

BACKGROUND: Existing ready-to-use supplementary and therapeutic foods (RUSFs and RUTFs) have had limited acceptance and effectiveness in Cambodia. This has hampered the treatment and prevention of child malnutrition. An innovative, locally produced, multiple micronutrient fortified lipid-based nutrient supplement (LNS) has been developed for use as an RUSF. Unlike most RUSFs, which contain milk, this product contains fish as the animal protein. Few RUSFs have been formulated using non-milk animal-source foods and they have not been widely tested. An acceptability trial that was conducted on this novel RUSF in June 2015 demonstrated that children will eat the RUSF and that caregivers will feed it to their children. The current trial aims to evaluate the effectiveness of the RUSF in preventing growth faltering and improving micronutrient status in Cambodian children. METHODS AND ANALYSIS: This trial is a six-month, prospective, cluster randomised, non-blinded controlled trial among infants in peri-urban Phnom Penh. The trial aims to establish the superiority of the novel RUSF, compared to three alternatives (Corn-Soy Blend Plus Plus (CSB++) and Sprinkles micronutrient powders as active comparators, and the unimproved diet as a control). The allocation ratio is 1:1. Healthy children (N = 540) aged six to eleven months will be recruited. Data will be collected at baseline, and monthly thereafter for a period of six months. Participants will be provided with a monthly supply of the food to which their village has been allocated. DISCUSSION: There is an urgent need to develop locally produced and culturally acceptable RUSFs, and to compare these with existing options in terms of their potential for preventing malnutrition, in Cambodia and elsewhere. This trial will contribute much-needed data on the effectiveness of supplementary foods with an animal-source food other than milk, by comparing a novel RUSF based on fish to one that uses milk (CSB++). Moreover, it will deepen the understanding of the impact of multiple micronutrients provided with or without macronutrients, by comparing the novel RUSF and CSB++, which combine macronutrients with multiple micronutrients, to Sprinkles, which contains no macronutrients. In addition, it will augment the body of evidence from Asia. TRIAL REGISTRATION: ClinicalTrials.gov, Identifier: LNS-CAMB-INFANTS-EFF; NCT02257762 .

Storage conditions and packaging greatly affects the stability of fortified wheat flour: Influence on vitamin A, iron, zinc, and oxidation.

Micronutrient deficiencies result in irreversible physical and cognitive consequences. Fortification of flour is widely applied to address micronutrient deficiencies, but vitamin losses can occur during the storage of fortified products. This work aimed at assessing the combined influence of different factors on vitamin A retention and the oxidative status of wheat flours: storage duration (up to 6months), temperature during storage, relative humidity within storage facilities, type of packaging (oxygen-permeable or not), and premix composition (with or without ferrous sulphate). Vitamin A degradation was high and occurred rapidly: more than 45% was lost within 3months in the mildest conditions, whereas over 85% was lost within 3months in the most severe conditions. Vitamin A retention was related to the extent of oxidation reactions that occurred in flours during storage, and the factors that mostly affected vitamin A retention were the storage duration, the type of packaging and the temperature.

Crossover trial to test the acceptability of a locally produced lipid-based nutrient supplement (LNS) for children under 2 years in Cambodia: a study protocol.

INTRODUCTION: The acceptability and efficacy of existing ready-to-use supplementary and therapeutic foods has been low in Cambodia, thus limiting success in preventing and treating malnutrition among Cambodian children. In that context, UNICEF and IRD have developed a locally produced, multiple micronutrient fortified lipid-based nutrient supplement. This food is innovative, in that it uses fish instead of milk as the animal source food. Very few supplementary foods have non-milk animal source foods, and in addition they have not been widely tested. This trial will assess the novel food's acceptability to children and caregivers. METHODS AND ANALYSIS: This is a cluster-randomised, incomplete block, 4×4 crossover design with no blinding. It will take place in four sites in a community setting in periurban Phnom Penh. Healthy children aged 9-23 months (n=100) will eat each of four foods for 3 days at a time. The amount they consume will be measured, and at the end of each 3-day set, caregivers will assess how well their child liked the food. After 12 days, caregivers themselves will do a sensory test of the 4 foods and will rank them in terms of preference. ETHICS AND DISSEMINATION: Ethical clearance was received from the University of Queensland Medical Research Ethics Committee (2014001070) and from Cambodia's National Ethics Committee for Health Research (03/8 NECHR). REGISTRATION: ClinicalTrials.gov, identifier: LNS-CAMB-INFANTS; NCT02257437. Pre-results.

An Assessment of the Potential Impact of Fortification of Staples and Condiments on Micronutrient Intake of Young Children and Women of Reproductive Age in Bangladesh.

Bangladesh has experienced rapid economic growth and achieved major health improvements in the past decade, but malnutrition rates remain high. A nationally representative study conducted in 2011 assessed the dietary habits of 841 children 24-59 months old, 1428 children 6-14 years old, and 1412 nonpregnant, nonlactating women. The study's objective was to assess dietary intakes of key micronutrients and the consumption pattern of potentially fortifiable foods, and then to model the potential impact of the fortification of key staple foods. The current intakes of several micronutrients-namely, iron, zinc, folate, vitamin A, and vitamin B12-were found to be insufficient to meet the needs of Bangladesh's children and women. The fortification of rice with iron and zinc and edible oil with vitamin A has the potential to fill a significant part of the nutrient gap, as these are consumed widely and in significant amounts. Wheat flour and sugar are not as promising food vehicles in the Bangladeshi context, as they were consumed by a smaller portion of the population and in smaller amounts. In conclusion, fortification of rice and oil is recommended to address the large gap in micronutrient intakes.

Low Urinary Iodine Concentration among Mothers and Children in Cambodia.

A 2014 national assessment of salt iodization coverage in Cambodia found that 62% of samples were non-iodized, suggesting a significant decline in daily iodine intakes. The Cambodian Micronutrient Survey conducted in 2014 (CMNS-2014) permitted obtaining national data on urinary iodine concentrations (UIC) to assess iodine status and whether iodized salt use had an impact. Urine samples were collected from mothers (n = 736) and children (n = 950). The median UIC was 63 µg/L and 72 µg/L in mothers and children respectively. More than 60% of mothers and their children had a UIC < 100 µg/L, thereby indicating a serious public health problem. Iodine status was significantly lower among mothers and children living in rural areas, belonging to the poorest socioeconomic category, or living in a household not using iodized salt. The limited enforcement of the legislation for iodized salt has resulted in a major decrease in the prevalence of iodized salt, which in turn has compromised iodine status in Cambodia. It is essential for the government to enhance enforcement of the iodized salt legislation, and implement short term strategies, such as iodine supplementation, to prevent an increase of severe complications due to iodine deficiency in the Cambodian population.

Beyond Effectiveness--The Adversities of Implementing a Fortification Program. A Case Study on the Quality of Iron Fortification of Fish and Soy Sauce in Cambodia.

Fortification of fish and soy sauces is a cost-effective strategy to deliver and increase iron intake in the Cambodian diet, as both are widely consumed by the entire population. In order to qualify as fortified sauces recognized by international regulations, iron content must be between 230 and 460 mg/L, whilst nitrogen and salt should contain no less than 10 g/L and 200 g/L respectively. This survey aims to analyze the progress of the fortification program. Through a better understanding of its obstacles and successes, the paper will then consider approaches to strengthen the program. Two hundred and fifty two samples were collected from 186 plants and 66 markets in various provinces. They were then analyzed for iron, nitrogen and salt content. The study demonstrates that 74% of fortified fish and soy sauces comply with Cambodian regulations on iron content. 87% and 53.6% of the collected samples do not have adequate level of nitrogen and salt content, respectively. The paper will discuss additional efforts that need to be implemented to ensure the sustainability of the project, including the need to: (i) comply with International Codex; (ii) adopt mandatory legislation; and (iii) ensure enforcement.

Stability of Vitamin A, Iron and Zinc in Fortified Rice during Storage and Its Impact on Future National Standards and Programs--Case Study in Cambodia.

Fortified rice holds great potential for bringing essential micronutrients to a large part of the world population. The present study quantified the losses of three different micronutrients (vitamin A, iron, zinc) in fortified rice that were produced using three different techniques (hot extrusion, cold extrusion, and coating) and stored at two different environments (25 ± 5 °C at a humidity of 60% and 40 ± 5 °C at a humidity of 75%) for up to one year. Fortified rice premix from the different techniques was mixed with normal rice in a 1:100 ratio. Each sample was analyzed in triplicate. The study confirmed the high stability of iron and zinc during storage while the retention of vitamin A was significantly affected by storage and the type of techniques used to make rice premix. Losses for iron and zinc were typically <10% for any type of rice premix. After 12 months at mild conditions (25 °C and humidity of 60%), losses for vitamin A ranged from 20% for cold extrusion, 30% for hot extruded rice 77% for coated rice premix. At higher temperatures and humidity, losses of vitamin A were 40%-50% for extruded premix and 93% for coated premix after 6 months. We conclude that storage does lead to a major loss of vitamin A and question whether rice is a suitable food vehicle to fortify with vitamin A. For Cambodia, fortification of rice with iron and zinc could be an effective strategy to improve the micronutrient status of the population if no other food vehicles are available.

Influence of light exposure and oxidative status on the stability of vitamins A and D3 during the storage of fortified soybean oil.

Food fortification is implemented to address vitamins A and D deficiencies in numerous countries. The stability of vitamins A and D3 was assessed during a two-month period reproducing the usual oil storage conditions before sale to consumers. Soybean oils with different oxidative status and vitamin E contents were stored in the dark, semi-dark, or exposed to natural light. Lipid peroxidation took place after 3 weeks of storage in dark conditions. After 2 months, the vitamin A and D3 losses reached 60-68% and 61-68%, respectively, for oils exposed to natural light, and 32-39% and 24-44% in semi-dark conditions. The determining factors of vitamin A and D3 losses were (in decreasing order) the storage time, the exposure to light and the oxidative status of the oil, whereas vitamin E content had a protective role. Improving these parameters is thus essential to make vitamins A and D fortification in oils more efficient.

Quality of vegetable oil prior to fortification is an important criteria to achieve a health impact.

Unbranded palm cooking oil has been fortified for several years and can be found in the market with different oxidation levels. This study aimed to investigate the stability and shelf life of unbranded, bulk, vitamin A-fortified palm oils with the most commonly observed oxidation levels in Indonesia. Three types of cooking oils were tested: (i) cooking oil with a peroxide value (PV) below 2 mEq O2/kg (PO1); (ii) cooking oil with a PV around 4 mEq O2/kg (PO2); and (iii) cooking oil with a PV around 9 mEq O2/kg (PO3). The oil shelf life was determined by using accelerated shelf life testing (ASLT), where the product was stored at 60, 75 and 90 °C, and then PV, free fatty acid and vitamin A concentration in the oil samples were measured. The results showed that PO1 had a shelf life of between 2-3 months, while PO2's shelf life was a few weeks and PO3's only a few days. Even given those varying shelf lives, the vitamin A loss in the oils was still acceptable, at around 10%. However, the short shelf life of highly oxidized cooking oil, such as PO3, might negatively impact health, due to the potential increase of free radicals of the lipid peroxidation in the oil. Based on the results, the Indonesian government should prohibit the sale of highly-oxidized cooking oil. In addition, government authorities should promote and endorse the fortification of only cooking oil with low peroxide levels to ensure that fortification is not associated with any health issues associated with high oxidation levels of the cooking oil.

Considerations for rice fortification in public health: conclusions of a technical consultation.

Fortification of staple foods and commonly used condiments with vitamins and minerals has been considered one of the most cost-effective interventions to prevent and control micronutrient deficiencies. Because of its wide local consumption, acceptability, reach, and quantum of consumption, rice (Oryza sativa) far exceeds the requirements of a staple food vehicle that can be considered for fortification purposes at a population-level intervention. The World Health Organization (WHO) has the mandate to develop evidence-informed guidelines for the fortification of staple foods as a public health intervention, including rice fortification with micronutrients. The WHO, in collaboration with the Global Alliance for Improved Nutrition (GAIN), convened a consultation on "Technical Considerations for Rice Fortification in Public Health" in Geneva, Switzerland on October 9-10, 2012 to provide technical inputs to the guideline development process, particularly with reference to feasibility and implementability. The industrial and regulatory technical considerations in rice fortification, as well as the considerations for implementing it as a public health strategy and assuring equitable access and universal coverage, were reviewed in this consultation. This paper summarizes the discussions and priority research areas for the forthcoming years.

Stability and retention of micronutrients in fortified rice prepared using different cooking methods.

Fortified rice holds great potential for bringing essential micronutrients to a large part of the world population. However, it is unknown whether differences in cooking methods or in production of rice premix affect the final amount of micronutrient consumed. This paper presents a study that quantified the losses of five different micronutrients (vitamin A, iron, zinc, folic acid, and vitamin B12) in fortified rice that was produced using three different techniques (hot extrusion, cold extrusion, and coating) during cooking and five different cooking methods (absorption method with or without soaking, washing before cooking, cooking in excess water, and frying rice before cooking). Fortified rice premix from six different producers (two for each technique) was mixed with normal rice in a 1:100 ratio. Each sample was prepared in triplicate, using the five different cooking methods, and retention of iron, zinc, vitamin A, vitamin B12, and folic acid was determined. It was found that the overall retention of iron, zinc, vitamin B12, and folic acid was between 75% and 100% and was unaffected by cooking method, while the retention of vitamin A was significantly affected by cooking method, with retention ranging from 0% (excess water) to 80% (soaking), depending on the cooking method and producer of the rice premix. No systematic differences between the different production methods were observed. We conclude that different cooking methods of rice as used in different regions of the world do not lead to a major loss of most micronutrients, with the exception of vitamin A. The factors involved in protecting vitamin A against losses during cooking need to be identified. All production techniques of rice premix yielded similar results, showing that coating is not inferior to extrusion techniques. Standard overages (50%) for vitamin B12 and folic acid are too high.