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International Journal of Health Sciences and Research www.ijhsr.org ISSN: 2249-9571

Review Article

Food Fortification to Combat Deficiencies and Its Impact on Sustainable Development Goals

Lovedeep Nagar1, Harvinder Popli2, Aayushi Gupta1, Manish Ruhela1

1Research Scholar, 2Professor, Delhi Pharmaceutical Sciences and Research University, Pushp Vihar, Sector-3, M.B Road, New Delhi -110017

Corresponding Author: Lovedeep Nagar

ABSTRACT

Micronutrients are essential for the growth, brain and body development and for immunity against the diseases in minute quantities and include and minerals. These are provided by and external sources as the body cannot synthesize them. Micronutrient deficiency is a issue with resulting in poor physical and mental development, mental retardation and blindness in the vulnerable population including young children, pregnant and lactating women and elderly. One third to half of the global population is affected by micronutrient deficiency affecting society in terms of unrealized potential and economic productivity loss. fortification is a safe and effective tool that improves intake of and restores the amount lost during processing by providing key nutrients in food. The micronutrient deficiencies affect the sustainable development goals. The technological and regulatory factors govern the choice of any combination of food and food vehicle. The vast range of are used for fortification and some of them are and -based products, and dairy products, , and oils, beverages and the condiments such as salt, and soy sauce. The fortification vehicles used in foods differ from country to country. For sustainable over the long term, the food processors require an effective program for monitoring compliance. The educational program creates awareness and helps people to teach about the benefits of food fortification. Keyword: Food fortification, deficiencies, micronutrients, sustainable development goals, regulatory.

INTRODUCTION to long-term solution is food fortification in According to the estimates of the a population. [5] World Health Organisation more than 2 According to WHO estimates, 190 billion people have deficiencies of key million preschool children and 19.1 million vitamins and nutrients, particularly pregnant women globally were A, iodine, iron and . [1] The pregnant and deficient (have serum <0.70 μmol/l), lactating women and young children are [4] over 100 million women of reproductive found to be the most vulnerable groups age have deficiency of iodine [6] and also affected to micronutrient deficiencies. The 82% of pregnant women over the world do majority of populations affected are from not have adequate zinc intakes to meet developed countries where micronutrient normal pregnancy needs. [7] Iron deficiency deficiencies coexist. [2-4] The strategy that was widespread and 1.62 billion people prevents vitamin and deficiencies globally were anemic, with apical and can be used safely and effectively pervasiveness among preschool children includes food fortification. To reduce (47%) leaded by pregnant women (42%). [8] specific nutrient deficiencies, the medium- Substandard status of vitamin B6 and B12

International Journal of Health Sciences & Research (www.ijhsr.org) 307 Vol.8; Issue: 7; July 2018 Lovedeep Nagar et al. Food Fortification to Combat Micronutrient Deficiencies and Its Impact on Sustainable Development Goals were seen in developing countries. [9] The U.S. Preventive Service Task Force and mortality data of WHO demonstrated due to published updated guidelines in 2009. [16] iron deficiency 0.8 million deaths attributed India has focused on addressing the each year and similar rate of deaths was deficiencies of iodine, vitamin A and iron seen due to . Food since historically. The vanaspati was fortification helps in eliminating nutritional fortified since 1953 with vitamin A and deficiencies like , , beriberi and mandatory fortification of salt with iodine . The emergent deficiencies like was done since 1962. [17] leads to neural tube defects, zinc These strategies were universal in affects child growth and selenium causes developed countries and were deployed by cancer. [5] Effects are not only limited to many middle-income countries. The nutrient health parameters but affected the deficiencies in industrialized countries have economies through physical and mental been eradicated with rich diet and disabilities altering work productivity. [10] consumption of fortified foods like juices, The wheat and wheat products, corn, salt, flour, , sugar and milk. [11] , milk and milk products, salt, sugar, cooling oils, condiments and breakfast FOOD FORTIFICATION cereals are the most widely used food Food fortification, restoration and vehicles for fortification. They offer enrichment are considered as similar terms. channels for delivery of micronutrients and According to WHO, food fortification is the are within the reach of market in developing assimilation of one or more ingredients to countries. [11] food, whether present in the food or not, for preventing or improving a known deficiency HISTORY associated with one or more ingredients in The nutrient addition to staple foods the population or in specific groups of the is not a novel concept and was prevalent in population. Restoration is the addition of a Europe and North America for over 70 food nutrient which may be lost during the years ago to deal with micronutrient process of Good Manufacturing Process deficiencies. [11] (GMP) or storage and handling procedures. In the early 1920 century, iodization of salt Enrichment is the restoration of vitamin and began in Switzerland [12] and minerals which are lost during the of America, [13] Denmark introduced processing and is substitutable with the vitamin A-fortified margarine in 1918, and fortification. [18] vitamin A-fortified milk and iron and B In food fortification, the commonly complex flour introduced in the 1930s in eaten and centrally processed foods are developed countries. [5] In the United States identified to ensure fortification during food in 1932, milk fortification with production and distribution systems. The was done due to the occurrence of rickets in condiments and staple foods are consumed children. Further, in 1941, bread and flour by a greater section of the population and were fortified with B vitamins. [5] In 1992, therefore are choice for fortification. The U.S. Service recommended food vehicle choice is limited to staple all pregnant women must consume 400 µg foods and condiments in developing of folic acid daily in addition to natural countries and includes cereals, fats and oils, uptake of from food to prevent salt, and sauces. For fortification, neural tube defects. [14] In 1998, Institute of vitamin A, D, iodine, iron, folic acid, zinc Medicine (IOM) recommended daily uptake and B-complex vitamins are the vitamins of 400 µg of folic acid either from fortified and mineral that can be used. [11] food or supplements with a daily intake of a Fortification of food vehicles as per normal diet for pregnant women. [15] These WHO occurs in three major approaches: recommendations were strengthened by mass, targeted and market driven. [5] The

International Journal of Health Sciences & Research (www.ijhsr.org) 308 Vol.8; Issue: 7; July 2018 Lovedeep Nagar et al. Food Fortification to Combat Micronutrient Deficiencies and Its Impact on Sustainable Development Goals widely consumed foods by population such conforms to specifications for acceptable as wheat, milled cereals, salt, oils and fats nutrients and quantities. The mass and and sugar are involved in mass fortification targeted fortification has focus on [5] to overcome unacceptable public health micronutrients that are required by most of risk of becoming deficient in particular the population. [19] The food vehicles widely micronutrients. The fortification of staple used are grouped into three categories: foods is cost-effective on a massive scale. staples (wheat, oils, and rice), condiments The fortification of few expensive staple (salt, soy sauce, sugar) and finally the foods leads to broader micronutrients processed commercial foods (noodles, dissemination throughout the population, infants complementary foods, dairy especially to poor. The foods consumed by products). [5] specific population sub-groups such as Vitamin A, the -soluble vitamin is infants leading to increase intake for that important for immune system and for vision specific group are included in targeted and is added to staple foods such as rice, fortification. The complementary foods for cereal grains and oils (Figure 1). young children are approached in targeted Fortification of vitamin A helps to avoid fortification. For market-driven fortification, vitamin A deficiency, which can cause the food manufacturer fortifies some of the visual impairment and increased products as value-added products and susceptibility to illness. [18]

Figure 1- Diagram showing cereal flour fortification

The fortification of wheat and maize flour and rice is done to prevent the nutritional anaemia, birth defects of brain and spine enhance productivity leading to economic progress. Figure 2 depicts the effects of wheat, flour and maize fortification. [20]

Figure 2- Effects of wheat, rice and maize fortification

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Table 1- Role of vitamins and minerals used in flour and rice fortification includes: [20] Micronutrients Functions Folic acid (vitamin B9) Reduces neural tube birth defects Zinc Strengthens immune system (vitamin B3) Prevents Pellagra, a skin disease (vitamin Boosts , and fats B2) (vitamin B1) Prevents beriberi, a nervous system disease Enables functioning of the brain and nervous system Vitamin D Improves bone health by allowing absorption of Vitamin A Childhood blindness and lowers the ability of individual’s to tackle infections Calcium Makes bones stronger, helps nerve muscles to transmit messages, functioning of muscles and blood clotting Selenium Helps in thyroid gland functioning and reproduction Vitamin B6 Metabolism involving reactions

Food fortification is an attentive extreme, where many -related public health strategy with the benefit of deficiencies been eradicated either reaching larger at-risk population groups diminished. [21] Although the extensive over existing food delivery systems, without accession of nutrients to food and fresh compelling major changes in current produce fortification is not allowed. The consumption patterns. It is a cost-effective fortification of meat, poultry and fish way to improve population’s nutrient uptake products is also not allowed by the and fortified foods have the advantage of government of US and European countries preserving steady body stores. [10] which also prohibits the fortification of unprocessed foods. [18] IMPORTANCE OF FOOD According to British Nutrition FORTIFICATION Foundation, around 50 percent of adults in Staple foods that are produced the UK are lacking vitamin D. Deficiency of within a particular region can lack particular vitamin D is a choice of concern, as disease nutrients due to reasons such as soil region rickets returned to the UK in current years. or inherent adequacy from a normal diet. [22] The sufficient levels of vitamin D are not Further addition of micronutrients to obtained through foods and most people are condiments and staples can prevent not exposed to sunlight and result in the deficiency of diseases on large scale. [18] high occurrence of in The original purpose of food many countries. The foods that are fortified fortification is to decrease the nutritional with vitamin D are yoghurt, bread, and deficiencies occurrence, specifically which juice. The fortified foods increase the levels lacks access to essential nutrients in of serum vitamin D and 25-hydroxyvitamin sufficient amounts. People living in D and similar bioavailability of vitamin D is developed countries, like Europe, U.S., as obtained from fortified foods and well as those living in underdeveloped pharmaceutical preparations. [23] Marks & countries, where a variety of foods are not Spencer added Vitamin D and Omega 3 to available, get benefits of food fortification. the bread they packed in the response of Another advantage is food fortification concerned customers facing challenges to results in the elimination of expense of meet daily dietary amount. [22] transporting perishable foods, such as Fortification offers mostly eaten vegetables and fruits, meats and dairy foods more nutritious instead of forcing products to remote areas around the world. consumers to change their habits and this Food fortification results have been makes it successful. [20]

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Table 2- Micronutrient deficiencies with disorders and their prevalence around the world [5] Micronutrient Deficiency Pervasiveness Major Deficiency Disorders Fortifying vehicle Iodine 2 billion at risk Goiter, , Salt, bread disorders, increased risk of stillbirth, birth defects infant mortality, cognitive impairment Iron 2 billion Iron deficiency, anaemia, reduced learning Wheat and corn flours, bread, pasta, and work capacity, increased maternal and rice, salt, infant formulas and cookies infant mortality, low birth weight Zinc Largely estimated in the Poor pregnancy outcome, impaired Breakfast cereals, infant formulas, developing countries growth(Stunting), genetic disorders, cookies and diet beverages decreased resistance to infectious disease Vitamin A 254 million preschool Night blindness, xerophthalmia, increased Milk, margarine, yoghurts, soft cheese, children risk of mortality in children and pregnant sugar, and tea women Folate (Vitamin Insufficient data Megaloblastic anaemia, neural tube and Wheat and corn flours, bread, pasta, B9) other birth defects, heart disease, stroke, rice, cookies and infant formulas impaired cognitive function, depression Cobolamine Insufficient data Megaloblastic anaemia (associated with Breakfast cereals, diet beverages, Wheat (Vitamin B12) Helicobacter pylori-induced gastric and corn flours, bread, pasta, rice atrophy) Thiamine Insufficient data, estimated Beriberi (cardiac and neurologic), Wheat and corn flours, bread, pasta, (VitaminB1) as in developing countries Wernicke’s and Korsakov syndromes rice, infant formulas and cookies, and in , displaced (alcoholic confusion and paralysis) breakfast cereals, vegetable mixtures persons and amino acids Riboflavin Insufficient data, estimated Non-specific-fatigue, eye changes, Wheat and corn flours, bread, pasta, (Vitamin B2) as in developing countries dermatitis, brain dysfunction, impaired rice, vegetable mixtures and amino iron absorption acids, breakfast cereals and infant formulas and cookies Niacin (Vitamin Insufficient data, estimated Pellagra (dermatitis, diarrhoea, dementia, Wheat and corn flours, bread, pasta, B3) as in developing countries death) rice, breakfast cereals, cookies and and in famines, displaced infant formulas persons Vitamin B6 Insufficient data, estimated Dermatitis, neurological disorders, Wheat and corn flours, bread, pasta, as in developing countries convulsions, anaemia, elevated plasma rice, infant formulas, cookies and and in famines, displaced homocysteine breakfast cereals persons Vitamin C Common in famines, (fatigue, hemorrhages, low Diet beverages, juices and substitute displaced person resistance to infection, anaemia) drinks Vitamin D Extensive in all age groups, Rickets, osteomalacia, , Milk, margarine, yoghurts, soft cheese low exposure to ultraviolet colorectal cancer rays of the sun Calcium Insufficient data, estimated Decreased bone mineralization, rickets, , breakfast cereals, infant to be widespread osteoporosis formulas and cookies, juices, diet beverages and substitute drinks Selenium Insufficient data, common in Cardiomyopathy, increased cancer and Milk, pasta, corn and wheat flours, Asia, Scandinavia, Siberia cardiovascular risk, osteoarthropathy breakfast cereals, infant formulas and cookies, juices and spreads Widespread Increased dental decay risk Infant formulas and cookies, breakfast cereals, wheat and rice flour, milk, juices (Source: Adapted from Allen L et al. [5])

MICRONUTRIENT DEFICIENCIES IN infectious and chronic diseases, influencing VULNERABLE GROUPS- CHILDREN, morbidity, mortality and quality of life. [5] WOMEN AND ELDERLY In India, over 70% populations Micronutrient deficiencies have been consume less than half of RDA of outspread among 2 billion people in both micronutrients. [17] The largest proportion of developed and developing countries underweight children among the world is in affecting people of all genders and ages. [5] India, almost double as compared to Sub- The one third of two billion people suffering Saharan Africa. [24] The iron deficiency from micronutrient deficiencies is from affects 273.2 million children (0-59 India and this hidden hunger affects rich and months), Vitamin A deficiency affects 190 poor, urban and rural, old and young –with million pre-school children and the risk of children and women are at most risk. [17] iodine deficiency disorders affects more They also act as aggravating factors in than 35 million newborns. [25-27] In USA, the

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3.1% of pre-school children’s have anaemia inadequacy would lead to hypothyroid which is 58.4% in India. [17] cretinism [31] Micronutrient deficiency has been responsible for a broad range of non- Vitamin A deficiency- Vitamin A is vital specific physiological impairment, thereby micronutrient for normal visual system leading to decreased resistance to infections, functioning, growth and development, metabolic disorders and impaired physical epithelial cellular integrity maintenance and and psychomotor development. [19] Globally, immune functioning and reproduction. [30] the vitamin A deficiency was seen in 21% Deficiency of vitamin A leads to of children and suffered from increased xerophthalmia, [19] blindness, reduced death rates of diarrhoea, measles and immunity, growth impairment and greater malaria. The vitamin A deficiency resulted susceptibility to infectious diseases. [29] in about 800,000 deaths in children and Globally 21% children have vitamin A pregnant women and had 1.8% eye disease deficiency and suffer increased death rates effects globally. contributed from diarrhoea, malaria and measles. [19] to death of about 800,000 children. [28] As per reports of UNICEF, around 330,000 Zinc deficiency- Zinc deficiency is more child deaths annually are precipitated in prevalent among children in developing India by Vitamin A deficiency. [29] countries where diets are high in phytates and low in animal products. Diarrhoea Iron Deficiency- Deficiency of iron causes worsens due to intestinal loss during zinc anaemia and the symptoms are pale inner deficiency. Low activity and depressed eyelids, nailbeds, gums, tongue, lips and motor development is seen in vulnerable skin. Other symptoms are tiredness, children. [31] Zinc deficiency results in headaches and breathlessness. The pregnant 800,000 children death each year. [28] Zinc women and young children found to be at fortification resulted in children with great risk. Iron deficiency can cause early improved growth and reduced child neonatal mortality and maternal mortality. mortality and lower rates of diarrhoea, [19] malaria and pneumonia. [31]

Iodine deficiency- Iodine deficiency leads Selenium deficiency- Selenium deficiency to goitre and cretinism. Stunted physical and has been observed in China, Tibet, Russian mental growth is also seen with symptoms Federation and the New Zealand. Thyroid including mental deficiency, deaf-mutism, injury and decreased production of thyroid ataxia, dwarfism and hypothyroidism. The hormone is seen due to selenium deficiency. goitre can be prevented by proper intake of Keshan’s disease, an endemic iodine. [19] cardiomyopathy is caused due to selenium Iodine is needed for synthesis of deficiency mostly affecting children and thyroid hormones and plays major role in pregnant women. [31] cell replication. Iodine deficiency during gestation leads to abortions, congenital FOOD VEHICLES AND FORTIFYING anomalies, stillbirth, low birth weight, AGENTS cretinism, psychomotor defects and The common food vehicles adopted increased neonatal mortality. [19] Both for fortification from US Dietary selenium and iodine are involved in normal Supplement Fact Sheet from the Office of functioning of thyroid gland and their Dietary Supplements of National Institute of Health and are included in Table 3. [32]

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Table 3- Commonly used food vehicles and fortifying agents with rich foods Food Vehicle Fortifying Agents Rich Foods (Natural Sources) Salt Iodine, iron Seaweed including kelp, nori, kombu, arame, cranberries, organic navy beans and yoghurt, liver, meat and fish, legumes such as tofu, lentils and beans, dried fruits such as apricots, prunes and raisins Wheat and corn flours, Vitamin B complex, iron, Eggs, wholegrain bread and brown rice, peas, liver, milk, meat and fish, porridge, bread, pasta, rice folic acid, vitamin B12 broccoli, potatoes, soya beans, asparagus, chickpeas, peas, spinach, cheese Milk, margarine, Vitamins A and D Fatty fish like herring, tuna, mackerel and salmon, beef liver, cheese, egg yolks, yoghurt, soft cheese oysters, mushrooms and cow milk Sugar, monosodium Vitamin A Carrot, sweet potato, lettuce, milk, yoghurt, mango, kale, animal-sourced food glutamate, tea such as oily fish, liver, beef and lamb liver, cheese and butter Infant formulas, Iron, vitamins B1 and liver, meat and fish, legumes such as tofu, lentils, lamb, beef, eggs, nuts, oats, cookies B2, niacin, , oranges, green leafy vegetables such as spinach, turnip, kale, collards, chard, folic acid, zinc lettuce, Oysters, pumpkin and squash seeds, chickpea, mushroom and broccoli Vegetable mixtures Vitamins and minerals lamb, beef, eggs, nuts, oats liver, meat and fish, legumes such as tofu, lentils, amino acids and vegetables such as spinach, turnip, kale, collards, chard, lettuce, sweet potato, proteins lettuce, milk, yoghurt, egg yolks Soy milk, orange juice Calcium Cheese, yoghurt, sardines and salmon, almonds, collard greens, spinach, kale, turnips, milk, soybeans Juices and substitute Vitamin C Broccoli, Brussels sprouts, cauliflower, cauliflowers, red and green pepper, drinks spinach, cabbage and sweet potato, guava, orange, kale Breakfast cereals Vitamins and minerals Salmon, kale, seaweed, garlic, shellfish including clams and oysters, potatoes, beef liver, sardines, blueberries and egg yolks Diet beverages Vitamins and minerals Milk, lentils, spinach, salmon, kale, seaweed, garlic, shellfish including clams and oysters, potatoes, beef liver, sardines, blueberries and egg yolks

INITIATIVE TO ELIMINATE folic acid, zinc and vitamin B12 contribute NUTRIENT DEFICIENCIES to anaemia. These nutrients are added to Fortification is supported by wheat flour, maize flour and rice, more than organizations like UNICEF, the WHO, the 80 countries have made a legislation for it. U.S. Centers for Disease Control and [33] Prevention (CDC), the Global Alliance for SDG 2- Zero hunger: The 45% of deaths Improved Nutrition (GAIN) and Nutrition among children below 5 years are due to International to eliminate the nutrient malnutrition. About 2 billion people are deficiencies in vulnerable populations. [33] affected by stunting, as a risk of stunting In September 2015 the United increases with vitamin and mineral Nations embraced 17 Sustainable deficiencies. [33] Development Goals (SDGs) and The productivity in adults increases upon fortification of grain products is the primary appropriate intake of nutrients, leading to step for achieving SDGs. The SDGs can be enhanced agricultural production followed achieved by reducing deficiencies for by food supply growth and providing vitamins and minerals. Out of 17, grain assistance in hunger. [33] fortification helps to address eight of SDCs SDG 3-Good Health and well-being: by incorporating iron, zinc, B vitamins Fortification helps to attain goals of including folic acid, niacin, riboflavin, maternal and new-born health, infectious thiamine, B12 and vitamin B6 to rice, wheat disease and non-communicable diseases. [33] and maize flour. [33]  Maternal and New-born Health-Folic SDG 1- No : The 17% lower acid fortification lowers the birth defect, productivity is estimated in heavy manual risks of spine and brain. The labour and 5% in other manual labour in a fortification of wheat flour with folic population suffering from anaemia. The iron acid demonstrated the reduced birth deficiency leads to undeveloped mental defect incidents in meta-analysis at an capacity in children and affects their average of 46%. Infants born in anaemia academic potential and performance. during pregnancy have low weights with Further, childhood anaemia results in 2.5% less than 2500 grams or 5.5 pounds and drop in wages in adulthood followed by are at a greater risk of death and hampered productivity and economic diseases. There also occurs the greater growth. The deficiency of iron, riboflavin, risk of poor mental development in an

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early phase of childhood followed by require adults spend time for medical diabetes and heart disease at a later appointments, helping children in mobility stage. [33] and toileting activities and taking children  Infectious Disease- Zinc promotes for treatment. The patients immunity; provide resistance to require intensive and on-going medical infections and helps in proper growth attention. Thus, one can conclude that and development of nervous system. caregivers can either balance their careers or Deficiency of zinc increase malaria, balance their working schedule, with the pneumonia and diarrhoea risk. As per consequence of productivity losses. [33] reports of 2012, there seen 17% SGD 10-Reduced inequalities- Most of the inadequate zinc intake risk in the global burden of nutrient deficiencies is faced by population. The zinc deficiency was low and the middle-income countries, which responsible for 18% malaria, 16% lower resulted in greater risk of death, morbidity respiratory tract infections and 10% and vulnerability to negative health diarrhoea worldwide. [33] outcomes that could be alleviated. To fight  Non-communicable diseases- Anaemia development challenges, the fortification and diarrhoea are non-communicable was ranked as the third largest opportunity. [33] diseases. The deficiencies of vitamins and minerals cause nutritional anaemia The problems of vitamin and mineral and addition of iron, riboflavin, folic deficiencies were faced by low- middle- as acid, zinc and vitamin B12 reduces the well as high-income countries and SDG was risk in food during the milling process. aimed to overcome inequalities between and The deficiencies of vitamin A and zinc- within nations. The salt fortification with lead to diarrhoea, along with unsafe iodine, milk fortification with vitamin D and and sanitation as the leading risk wheat and maize flour fortification with factors. [33] thiamine and niacin in the 1920s, 1930s and SDG 5-Gender equality: Females are 1940s eradicated diseases like goitre, affected by anaemia largely than males. rickets, beriberi and pellagra in the United [33] Rates of anaemia remain higher in females States. by the end of puberty and through SDG 11- Sustainable cities- The residents reproductive years than in males. Thus, of urban areas are more likely to get boosting iron intake in females via fortified benefited of flour and rice fortification. To foods reduces anaemia followed by greater improve public health mass food performance and work productivity and fortification is an effective way but is helps in attaining gender equality. [33] sometimes overlooked as it doesn’t reach SDG 8-Economic Growth- As per the poor. The larger number of people lives in Global Nutrition Report 2017, the low and cities than rural areas and around 30% urban middle-income countries stated 16:1 benefit dwellers reside in slum conditions. China, to cost ratio in fortifying foods. The India, Brazil, Pakistan and Bangladesh fortification with folic acid prevents included 431 million people in urban slum healthcare expenditures used in the population. The fortification of grain treatment of birth defects of brain and spine. provides an opportunity to enhance intake of The Spina bifida is incurable and common nutrients in a significant proportion of [33] birth defect often results in paralysis, bowel population counting urban poor also. and bladder control problems. In 2002, For effective fortification programmes and according to a study, the total lifetime cost to address the challenges of nutritional for a patient with spina bifida was deficiencies in vulnerable population and US$620,484 including the cost of medical among others, the key players are: care, indirect costs and development  dominant individual to support services. Also, children with spina bifida fortification

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 an institution with research capacity to of vitamin problems in aseptically processed monitor the impact foods has been ascribed to dissolve and  to fortify food headspace oxygen, oxygen and light  policymakers to ensure nationwide permeability of the packaging material and fortification storage temperature dependent, commodity-  regulatory agencies for ensuring and specific reaction. Due to dissolved and monitoring compliance headspace oxygen, quick initial losses of The primary consideration for fortification vitamin C activity have been observed in is a national alliance in-country followed by aseptically processed milk followed by participation by public, private and civic folate losses as vitamin C plays a major role sectors and thereby, creating an in folate protection. Heavy losses of vitamin understanding of health and economic B6 and B12losses have also been reported [33] during storage of aseptically processed milk benefits of food fortification. [18] (Oamen, 1989). IMPACT OF OTHER Irradiation and Microwaves- Food TECHNOLOGIES ON METHODS OF processing uses irradiation to a limited FOOD FORTIFICATION extent and does not impact upon To attain necessary level of nutrients fortification procedures to a large extent. It in fortifying foods, the processing and is commonly used in the prevention of storage losses must be estimated by the insect infestation in grains. Upon manufacturers. The storage and processing irradiation, there is a higher loss of Vitamin losses and fortification procedures were B1in milled grains as compared to whole affected by the introduction of new grains. The exclusion of oxygen reduces the processes, equipment and packaging vitamin loss during storage and irradiation. [35] materials. [18] Thermal processes- aimed at the The effectiveness of fortification destruction of micro-organisms, inactivation technology is boosted by efforts of research of and toxic factors and flavour and development. Stability of iodine and texture modification. The selection of compounds in salt and vitamin A in cooking heat treatment is done on the basis lethality oils is improved by better refining of the process to provide safe product procedures and packaging. The absorption understated storage conditions. [34] of foods fortified with iron is enhanced by the use of stabilizers and enhancers. [11] Packaging Materials- In thermal processing, use of retort pouches and deformable containers affects processing REGULATIONS AND STANDARDS procedures followed by thermal degradation For effective food fortification, the of nutrients. The packaging plays an government should ensure laws and essential role in the application of aseptic regulations providing legal authority and processing technologies and has proper regulatory framework. The implications for fortification techniques. For regulatory controls and fortification aseptically processed foods shelf life can standards safeguard consumers from the risk of purchasing and consuming nutritionally surpass 1 year and required overages can be [11] calculated by considering the storage loss inadequate, misbranded or unsafe food. over the entire period. The product is cooled All fortified foods must be manufactured, preceding packaging in sterile containers packed, labeled, handled, distributed and during aseptic processes, resulting in higher sold only in compliance with the specified standards under provisions of the Act and levels for headspace oxygen and dissolved [17] oxygen than in hot-filled products or regulations. traditional thermal process requiring vacuum sealing before processing. The loss

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MONITORING AND EVALUATION introduced in Denmark by 1987 and in There is a great need to monitor the Spain by 1994. [11] quality of fortified product and its The rapid growth of fortified foods micronutrient content due to increasing food was seen in the last two decades. The fortification programs all over the world. fortification of salt with iodine is most The contribution of micronutrient in the successful fortification and iodized salt is alleviation of micronutrient deficiencies also used by the major population in 130 needs to be evaluated. The fortified product countries. About 70 million newborns each must encompass adequate micronutrient and year are protected from the risk of mental must be ensured that it reaches the targeted impairment resulted by iodine deficiency population. The production level monitoring since 2006 and two-thirds of salt consumed is important and is done via quality by developing countries is iodized salt assurance, the monitoring at different levels (UNICEF, 2006). The double fortification of distribution chain-from production to of salt with iodine and iron has gained warehouse following sale, retail and attention and is produced in India and household level also need to be done. [11] further distributed in many countries to The biological impact evaluation, to weaker segments of the population through demonstrate effectiveness must be public programs and commercial channels. conducted after 2 or 3 years to determine [11] The double fortified salt showed how well the micronutrients are absorbed improvements in iron deficiency indicators and contributed in reducing the occurrence such as haemoglobin, ferritin and body iron of deficiency in the population. The in a randomized controlled double-blinded nutritional status of women of childbearing study after 9 months in women tea pickers. age showed intense improvement in [36] The single-blinded controlled efficacy reducing neural tube defects by folic acid study done in tribal areas of East Godavari fortification. [11] district, AP and double-blinded controlled study in schools of Hyderabad by NIN GLOBAL FOOD FORTIFICATION showed a notable reduction in anaemia. [37] EXPERIENCE Over 80 countries mandated cereal grain Over the last 70 years in developed fortification and many countries are and developing countries, the major role fortifying milk and edible oils. [17] was played by food fortification on the The staple foods fortification with health of the population by eliminating micronutrients has grown significantly. The many nutritional deficiencies. The 28% of global market in more than 63 effectiveness of food fortification in countries is fortifying flour with iron, folic eliminating micronutrient deficiencies has acid and other nutrients. The fortification of been demonstrated in various studies. The wheat and industrially milled corn flour has flour fortification in Canada was done with grown widely in the United States and vitamin B in 1944 and dropped the wheat flour fortification has grown with deficiency to negligible levels within 4 excessive interest in South and South-East years. The 30-70% neural tube defects in Asia. In the Middle East and North Africa, newborns were reduced in the United States, iron and folic acid have been added to cereal Canada and Chile upon introduction of flour in several countries. [11] The impact of mandatory folic acid fortification of cereal- fortified wheat flour was tested in a study on grain after 1998. The fortified breakfast anaemia prevalence in Darjeeling, showed cereals in France, Ireland, Spain and the decrease levels of anaemia in adolescent United Kingdom demonstrated increased girls, pregnant and lactating women and intakes of vitamins and minerals in school-age children. [38] comparative dietary survey analysis. The At present, 14 countries mandated national fortification programs were milk fortification of which 11 fortifies milk

International Journal of Health Sciences & Research (www.ijhsr.org) 316 Vol.8; Issue: 7; July 2018 Lovedeep Nagar et al. Food Fortification to Combat Micronutrient Deficiencies and Its Impact on Sustainable Development Goals with both vitamin A and D. Costa Rica is school daily. Around 2.16 million MT of fortifying milk with iron and folic acid food grains are allotted by government while Canada and China are adding every year to feed 118.5 million children. calcium, Vitamin A and D to milk. The milk The Integrated Child Development Scheme fortification resulted in 18% lesser incidents (ICDS) supplies supplementary nutrition in of diarrhoea and 26% lesser incidents of Take Home Ration (THR) for pregnant pneumonia. [17] women, lactating mothers and children and The FSSAI of India at National hot cooked meal for children of age group Summit on Food Fortification in 2016 3-6 years. [17] launched standards for fortification of staple The cooking oils in Nigeria, foods like wheat flour, rice, oil, milk and Morocco, Yemen, Bangladesh, and Pakistan double fortified salt. The fortified logo was are fortified with vitamin A. The anaemia is launched by FSSAI to promote and reduced from 21% to 1% in Chilean infants differentiate regular products and fortified upon implementing national program products (Figure 3). The square around +F providing fortified milk to infants. [11] represents completeness while plus sign The lozenges are fortified and represents an addition of extra nutrition by distributed to pregnant and lactating vitamins and minerals to daily nutrition mothers, adolescent girls and children of 2-5 requirements. The ring represents good years of age in India, providing assurance of health, protection for healthy and active life. measured quantity intake and high This creates awareness among customers compliance for micronutrients. [11] and helps in selecting healthier food choices. [17] RISKS AND PROBLEMS ASSOCIATED WITH FOOD FORTIFICATION The food fortification often leads to excess intake of nutrients in individuals. The fortified processed products are safe, although the risk may be associated with some of them ranging from mild to severe. . Nutrient overdose-The excess addition of vitamins and minerals pose serious risks. The excess vitamin A intake Figure 3-Fortification logo reduces bone density also increases birth

defect risks and liver damage. The risk In Asia, national flour fortification of haemorrhagic stroke increases with has been implemented in Nepal, Pakistan excessive intake of vitamin E. As per and some states of India. The wheat and review was done by Annals of Internal maize flour fortification became mandatory Medicine intake of excessive amounts of in Nigeria and South Africa. The iron β-carotene then recommended could fortification of condiments like fish/soy lead to higher mortality risk. [39] The sauces emerged in Asia including China, excessive iron intake may cause Thailand and Vietnam. In Central America, cirrhosis, , type 2 the deficiency of vitamin A is eliminated by diabetes and cancer. The populations Guatemala’s sugar fortification program. [11] with genetic and acquired diseases are at In India, the government runs several greater risk in case of mass fortification programmes involving fortification, aims at and needs to be protected. [40] enhancing nutrient levels. The Mid-Day . Health risk- Although there is no direct Meal (MDM) Scheme provides fortified association of fortified foods with grains for children studying in schools up to overweight and obesity are higher in 8th class as part of hot cooked meal served at International Journal of Health Sciences & Research (www.ijhsr.org) 317 Vol.8; Issue: 7; July 2018 Lovedeep Nagar et al. Food Fortification to Combat Micronutrient Deficiencies and Its Impact on Sustainable Development Goals

calories with respect to whole foods and 3. Black RE, Allen LH, Bhutta ZA, Caulfield create a desire to eat more resulting in LE, De Onis M, Ezzati M, Mathers C, weight gain over the time. [39] Rivera J. Maternal and child undernutrition: . Medication complications- Fortified global and regional exposures and health foods may result in harmful interactions consequences. Lancet. 2008;371(9608):243- 260. with people taking other prescription 4. WHO. Global prevalence of vitamin A medications. The fortification of foods deficiency in populations at risk 1995-2005. with vitamins and minerals may result in WHO global database on vitamin A events of decreased absorption, failure deficiency. Geneva: World Health of treatment and increased mortality Organization; 2009. 55p. risk. [39] 5. Allen LD, de Benoist B, Dary O and Hurrell To establish dietary patterns and habits, RE. Guidelines on Food Fortification with surveys are to be done in many countries to Micronutrients. Geneva, Switzerland: WHO provide critical inputs in determining and FAO;2006. 341p. appropriate vehicles to be used in food 6. Leslie J. Women’s nutrition: the key to fortification. [18] improving family health in developing countries. Health Policy and Plan.

1991;6(1):1-19. CONCLUSION 7. Caulfield LE, Zavaleta N, Shankar AH, Processing of food involves the loss Merialdi M. Potential contribution of of nutrients, in order to counter such losses maternal zinc supplementation during foods are enriched with nutrients. This pregnancy to maternal and child survival. review focuses on the implications of Am Journal Clin Nutr. 1998;68(2):499S- fortification of foods with vitamins and 508S. minerals essential for the health of 8. Benoist B, McLean E, Egli I, Cogswell individuals and commonly used food M. Worldwide prevalence of anaemia 1993– vehicles in detail. The review also includes 2005: WHO global database on anaemia. the micronutrient deficiencies in the Geneva: World Health Organization; 2008. 40p. vulnerable population mainly women and 9. McLean E, de Benoist B, Allen LH. Review children and also the impact of fortification of the magnitude of folate and vitamin B12 in enhancing the quality of health. Food deficiencies worldwide. Food Nutr Bull. fortification is a nutritional intervention 2008;29(2):S38-51. program with a specifically defined target 10. Das JK, Salam RA, Kumar R, Bhutta ZA. population and its effectiveness depends on Micronutrient fortification of food and its whether or not, the fortified food is impact on woman and child health: a accepted, purchased and consumed by the systematic review. Systematic reviews. targeted population. Staple foods are 2013;2:67. fortified by the government or other 11. Venkatesh Mannar MG, Wesley Annie. authoritative bodies with the objective of Food Fortification. International Encyclopedia of Public Health. 2008; 622- overcoming endemic nutritional diseases 630 such as salt fortification with iodine or milk 12. Burgi H, Supersaxo Z, Selz B. Iodine fortification with Vitamin A which resulted deficiency diseases in Switzerland one in the prevention of goitre and vitamin A hundred years after Theodor Kocher’s deficiencies in various countries including survey: a historical review with some new India. goitre prevalence data. Acta Endocrinologica. 1990;123(6):577-590. REFERENCES 13. Marine D, Kimball OP. Prevention of 1. WHO. World Health Report 2000. Health simple goiter in man. Archives of Internal Systems: Improving Performance. Geneva: Medicine. 1920; 25(6):661-672. World Health Organization; 2000. 206p. 14. Centers for Disease Control. 2. Black RE. Micronutrients in pregnancy. Br J Recommendations for the use of folic acid Nutr. 2001;85(S2):S193-S197. to reduce the number of cases of spina

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How to cite this article: Nagar L, Popli H, Gupta A et al. Food fortification to combat micronutrient deficiencies and its impact on sustainable development goals. Int J Health Sci Res. 2018; 8(7):307-320.

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International Journal of Health Sciences & Research (www.ijhsr.org) 320 Vol.8; Issue: 7; July 2018