Consumption of a Double-Fortified Salt Affects Perceptual, Attentional, and Mnemonic Functioning in Women in a Randomized Controlled Trial in India.

Background: Iron deficiency and iron deficiency anemia have been shown to have negative effects on aspects of perception, attention, and memory.Objective: The purpose of this investigation was to assess the extent to which increases in dietary iron consumption are related to improvements in behavioral measures of perceptual, attentional, and mnemonic function.Methods: Women were selected from a randomized, double-blind, controlled food-fortification trial involving ad libitum consumption of either a double-fortified salt (DFS) containing 47 mg potassium iodate/kg and 3.3 mg microencapsulated ferrous fumarate/g (1.1 mg elemental Fe/g) or a control iodized salt. Participants' blood iron status (primary outcomes) and cognitive functioning (secondary outcomes) were assessed at baseline and after 10 mo at endline. The study was performed on a tea plantation in the Darjeeling district of India. Participants (n = 126; 66% iron deficient and 49% anemic at baseline) were otherwise healthy women of reproductive age, 18-55 y.Results: Significant improvements were documented for iron status and for perceptual, attentional, and mnemonic function in the DFS group (percentage of variance accounted for: 16.5%) compared with the control group. In addition, the amount of change in perceptual and cognitive performance was significantly (P < 0.05) related to the amount of change in blood iron markers (mean percentage of variance accounted for: 16.0%) and baseline concentrations of blood iron markers (mean percentage of variance accounted for: 25.0%). Overall, there was evidence that the strongest effects of change in iron status were obtained for perceptual and low-level attentional function.Conclusion: DFS produced measurable and significant improvements in the perceptual, attentional, and mnemonic performance of Indian female tea pickers of reproductive age. This trial was registered at clinicaltrials.gov as NCT01032005.

Double-fortified salt is efficacious in improving indicators of iron deficiency in female Indian tea pickers.

Poor iron status affects 50% of Indian women and compromises work productivity, cognitive performance, and reproduction. Among the many strategies to reduce iron deficiency is the commercial fortification of iodized table salt with iron to produce a double-fortified salt (DFS). The objective of this study was to test the efficacy of DFS in reducing iron deficiency in rural women of reproductive age from northern West Bengal, India. The participants were 212 women between 18 and 55 y of age who worked as full-time tea pickers on a large tea estate. Participants in the randomized, controlled, double-blind study were assigned to use either DFS or a control iodized salt for 7.5 to 9 mo. The DFS was fortified with 3.3-mg ferrous fumarate (1.1-mg elemental iron) per kg of iodized salt, whereas the control salt contained only iodine (47 mg/kg potassium iodate), and both salt varieties were distributed gratis to the families of participants at 0.5 kg/mo for each 2 household members. At baseline, 53% of participants were anemic (hemoglobin <120 g/L), 25% were iron deficient (serum ferritin <12 µg/L), and 23% were iron-deficient anemic. Also, 22% had a transferrin receptor concentration >8.6 mg/L and 22% had negative (<0.0 mg/kg) body iron stores. After 9 mo the participants receiving DFS showed significant improvements compared with controls in hemoglobin (+2.4 g/L), ferritin (+0.13 log10 µg/L), soluble transferrin receptor (-0.59 mg/L), and body iron (+1.43 mg/kg), with change in status analyzed by general linear models controlling for baseline values. This study demonstrated that DFS is an efficacious approach to improving iron status and should be further evaluated for effectiveness in the general population. This trial was registered at clinicaltrials.gov as NCT01032005.

Feasibility and optimization study of using cold-forming extrusion process for agglomerating and microencapsulating ferrous fumarate for salt double fortification with iodine and iron.

A microencapsulation-based technology platform has been developed for salt double fortification with iron and iodine, aiming to address two globally prevalent micronutrient deficiencies simultaneously. Specifically, ferrous fumarate was microencapsulated into a form of salt grain-sized premix, and then added into iodised salt. The earlier process involved fluidised-bed agglomeration followed by lipid coating. To improve physico-chemical properties of the iron premix, the use of cold-forming extrusion for agglomerating and microencapsulating ferrous fumarate was investigated and optimized in this study, leading to optimal formulations and operation parameters. Grain flours were suitable for forming an extrudable dough incorporating high percentages of ferrous fumarate. All extruded iron particles, regardless of binders used, were rich in iron and had excellent iron in vitro digestibility. The extruded iron particles formed the basis of the final, microencapsulated iron premixes with desired particle size (300-700 µm), and other physical, chemical, nutritional, and organoleptic properties suitable for salt fortification.

Folic acid fortification through existing fortified foods: iodized salt and vitamin A-fortified sugar.

BACKGROUND: Folic acid fortification of cereal-grain products has markedly improved folate status and reduced the risks of neural tube defects and other chronic diseases in the populations participating in fortification programs. To more broadly extend its benefit to affected populations in developing countries, it would seem logical to incorporate folic acid fortification into existing or planned programs to minimize the incremental cost of this intervention. OBJECTIVE: To examine the feasibility of providing folic acid through ongoing programs for salt iodization and vitamin A fortification of sugar. METHODS: Folic acid was added to iodized salt and vitamin A-fortified sugar by various methods--direct blending as a powder, spraying onto the carriers as aqueous solution or suspension, or blending as a microencapsulated premix. The multiple fortified samples were subjected to a prolonged storage stability test, and the retentions of the added micronutrients were followed. RESULTS: Folic acid was generally stable when incorporated into Guatemalan iodized salt and vitamin A-fortified sugar. Even in the presence of encapsulated ferrous fumarate as an iron fortificant, samples retained > 80% in salt and approximately 70% in sugar samples respectively, after 9 months of storage at 40 degrees C and 60% relative humidity. The addition of folic acid as a dry premix made by extrusion was most effective in retaining both folic acid and the other added micronutrients. CONCLUSIONS: The fortification method had a pronounced impact on the stability of both folic acid and the other added micronutrients. Proper encapsulation may be required to ensure the stability of multiple fortified foods.

Miller's best/enhanced practices for flour fortification at the flour mill.

BACKGROUND: Cereal flour fortification has been identified as an effective mass fortification intervention as part of a national public health strategy to overcome micronutrient deficiencies and improve the health status of populations, especially women and children. OBJECTIVE: The effectiveness of cereal flour fortification programs requires the use of micronutrient premixes that provide the desired health benefits. METHOD: The Miller's Best/Enhanced Practices for Flour Fortification at the flour mill has been developed to provide specific guidance to millers and government officials to ensure that flour fortification practices are carried out in a way that results in the anticipated public health impact. RESULTS: The paper provides information specific to the use of micronutrient premixes, feeders, the fortification process, and quality control systems to ensure that both minimum and enhanced practices can be followed by the millers. CONCLUSIONS: Guidelines for basic and best/enhanced practices to be followed for each stage of the flour fortification process at the flour mill are presented. The paper is designed to be a companion to the Recommended Practices for the Production and Procurement of Premix used in Cereal Fortification Programs and supplementary to existing food quality manuals and systems, such as Good Manufacturing Practices, Food Quality Systems, and Hazard Analysis and Critical Control Points. Other stakeholders involved in flour fortification programs have the responsibility to follow best practices of their own to ensure optimum effectiveness.

Iron in vitro bioavailability and iodine storage stability in double-fortified salt.

BACKGROUND: Ferrous fumarate is useful in iron fortification because of its high bioavailability, mild taste, and relatively low cost. A ferrous fumarate premix for incorporation into salt has been developed by agglomerating ferrous fumarate with appropriate binder materials into salt-size particles followed by microencapsulation. OBJECTIVE: The bioavailability of iron is critical for the usefulness of double-fortified salt. This study examined the in vitro bioavailability of various iron forms in double-fortified salt and microencapsulated ferrous fumarate premixes prepared by various techniques in an effort to identify key processing factors affecting iron bioavailability. METHODS: Iron in vitro bioavailability was approximated through the rate of dissolution of iron in 0.1 N HCl, which closely approximates the acid in gastric juice. Iron in vivo bioavailability was tested using the hemoglobin repletion assay in rats. RESULTS: The materials and techniques used in microencapsulating ferrous fumarate had little effect on iron in vitro bioavailability: more than 90% of iron in the premixes was released during 2 hours of digestion in the simulated gastric fluid. By incorporating titanium dioxide in the coating materials, the dark reddish-brown color of ferrous fumarate was effectively masked, resulting in acceptable sensory qualities, while maintaining the stability of iodine in the salt. Iron in vivo tests in rats have confirmed that the ferrous fumarate microencapsulated in a lipid is highly bioavailable, with a bioavailability of 95% relative to ferrous sulfate. CONCLUSIONS: These findings were corroborated by field tests in southern India which demonstrated that double-fortified salt containing microencapsulated ferrous fumarate was effective in reducing the prevalence of iron-deficiency anemia and iodine-deficiency disorders.

Maize meal fortification is associated with improved vitamin A and iron status in adolescents and reduced childhood anaemia in a food aid-dependent refugee population.

OBJECTIVE: To assess changes in the Fe and vitamin A status of the population of Nangweshi refugee camp associated with the introduction of maize meal fortification. DESIGN: Pre- and post-intervention study using a longitudinal cohort. SETTING: Nangweshi refugee camp, Zambia. SUBJECTS: Two hundred and twelve adolescents (10-19 years), 157 children (6-59 months) and 118 women (20-49 years) were selected at random by household survey in July 2003 and followed up after 12 months. RESULTS: Maize grain was milled and fortified in two custom-designed mills installed at a central location in the camp and a daily ration of 400 g per person was distributed twice monthly to households as part of the routine food aid ration. During the intervention period mean Hb increased in children (0.87 g/dl; P < 0.001) and adolescents (0.24 g/dl; P = 0.043) but did not increase in women. Anaemia decreased in children by 23.4% (P < 0.001) but there was no significant change in adolescents or women. Serum transferrin receptor (log10-transformed) decreased by -0.082 microg/ml (P = 0.036) indicating an improvement in the Fe status of adolescents but there was no significant decrease in the prevalence of deficiency (-8.5%; P = 0.079). In adolescents, serum retinol increased by 0.16 micromol/l (P < 0.001) and vitamin A deficiency decreased by 26.1% (P < 0.001). CONCLUSIONS: The introduction of fortified maize meal led to a decrease in anaemia in children and a decrease in vitamin A deficiency in adolescents. Centralised, camp-level milling and fortification of maize meal is a feasible and pertinent intervention in food aid operations.

Development of field test kits for determination of microencapsulated iron in double-fortified salt.

BACKGROUND: Efficacy studies have shown that salt double-fortified with iodine and iron can significantly reduce the incidence rates of iron-deficiency anemia and iodine-deficiency disorders. Double-fortified salt can be prepared by mixing microencapsulated iron compounds into conventionally iodated salt. Effective implementation of a double fortification program requires field-based analytical methods to ensure iron levels in double-fortified salt. OBJECTIVE: To develop semiquantitative and qualitative field test kits by adopting standard analytical methods for iron determination to the analysis of iron in double-fortified salt. METHODS: Thermal, mechanical, and chemical strategies were assessed to enable contact between analytical reagents and the encapsulated iron compounds during the analysis. A chemical approach using nonpolar solvents was adopted in semiquantitative and qualitative field tests. The fat coating of the iron premix was removed by solvents, releasing the iron for subsequent colorimetric determination. RESULTS: Both semiquantitative and qualitative field tests were based on initial removal of the microencapsulant, followed by iron quantitation. Solvent dissolution of the coating layer was most useful for rapid release of iron. A semiquantitative field test kit was developed using a mixture of 5% heptane and 95% tetrachloroethylene to free the iron, which was then determined by the 1,10-phenanthroline method. The field test had a useful detection range of 0 to 2,000 ppm of iron. Statistical analyses revealed that the results obtained with the kit correlated well with those obtained by standard laboratory methods (p < .001). A qualitative field test kit was developed to identify the presence of iron. Microencapsulated iron was freed with the use of tetrachloroethylene and then reacted with phenanthroline to form a visually observable coloration on the salt sample. CONCLUSION: Semiquantitative and qualitative field test kits for iron determination in double-fortified salt have been developed and tested. These kits could be useful in quality control of double fortification of salt in small salt-production facilities and in the field, particularly in developing countries.