Effects of preparation and cooking of folic acid-fortified foods on the availability of folic acid in a folate depletion/repletion rat model

The practice of food fortification with folic acid offers the potential to increase the folate intake of the general population. To fully exploit the potential of fortification for raising folate nutriture, appropriate food vehicles need to be selected. Selection should involve determination of the availability of folic acid as affected by characteristics of the carrier food, food matrix, food preparation, and cooking. The present study investigated the effects of preparation and cooking of a range of folic acid-fortified foods on the folate status of folate-deficient rats. Fifty-six weanling male rats (Wistar strain) were fed a folate-deficient diet containing 1% succinyl sulfathiazole for 28 days. Following depletion, six rats were randomly assigned to each of eight repletion diets containing cooked or uncooked meringue mix, quick bread mix, brownie mix, or pizza base mix. The test foods were fortified with 1400 microg of folic acid/kg of food and incorporated as 19% of the repletion diets. Each of the first four groups was pair-fed a diet containing a cooked fortified food with another group fed the corresponding uncooked fortified food. After a further 28 days, plasma, liver, and kidney folate concentrations were determined by microbiological assay. Mean plasma and liver folate concentrations of rats fed diets containing cooked fortified foods were similar to those of rats fed uncooked fortified foods. Preparation and cooking did not affect the availability of folic acid from the selected cereal-based convenience foods in this rat model system, suggesting that these foods are appropriate vehicles for fortification with folic acid.     

Folate Stability in Folic Acid Enriched Corn Masa Flour,Tortillas, and Tortilla Chips over the Expected Shelf Life

Neural tube defects occur at higher rates in Hispanic populations in the United States. Such populations would benefit from folic acid fortification of corn masa flour (CMF). This study evaluated folate stability in fortified CMFs and tortillas and tortilla chips made therefrom. There was no significant loss of folate during the six‐month shelf life of fortified tortilla CMF and tortilla chip CMF. There was a 13% loss (P < 0.05) of folate during tortilla baking and no loss during tortilla chip frying. Both tortillas and tortilla chips showed significant folate losses over the two‐month shelf life for these products, with a 17% loss in fortified tortillas and a 9% loss in tortilla chips. Folate in fortified CMFs, tortillas, and tortilla chips is relatively stable and comparable to the stability of folate in wheat flour and breads.     

National fortification of staple foods can make a significant contribution to micronutrient intake of South African adults

BACKGROUND: A national survey found that micronutrient deficiencies are prevalent in South African children, particularly calcium, iron, zinc, riboflavin, niacin, vitamin B6, folate, vitamin A, E and C. Mandatory fortification of maize meal and wheat flour were introduced in 2003 to combat some of the deficiencies found in children. To date however, there has not been a national survey on dietary intake in adults. OBJECTIVES: The main objectives of this study were to evaluate the micronutrient intake of the diet consumed by the average adult South African by means of secondary data analyses and secondly to evaluate the effects of fortification on selected nutrient intakes. STUDY DESIGN: Secondary data analysis was carried out with numerous dietary surveys on adults to create a database that included sampling (and weighting) according to ethnic/urban-rural residence in line with the population census, of which 79% were black Africans and the majority resided in rural areas. The effect of fortification was evaluated by substituting fortified foods in the diet for the unfortified products. SUBJECTS: The combined database used in this study comprised 3229 adults. RESULTS: Mean calcium, iron, folate and vitamin B6 intakes were very low particularly in women. Mean intakes of most micronutrients were lower in rural areas. Fortification of maize meal and wheat flour (bread) raised mean levels of thiamine, riboflavin, niacin, vitamin B6 and folate above the recommended nutrient intakes (RNIs). In women, despite fortification, mean iron intakes remained below the RNIs, as did calcium since it was not in the fortification mix. CONCLUSION: The average dietary intake of adults was of poor nutrient density, particularly in rural areas. Fortification of maize meal and wheat flour (bread) considerably improved mean vitamin B6, thiamine, riboflavin, niacin, folate and iron intakes as well as the overall mean adequacy ratio of the diet.     

Efficacy and safety of food fortification with calcium among adults in Finland

OBJECTIVE: To examine the efficacy and safety of foods fortified with calcium in the adult population in Finland. DESIGN: A simulation study based on the FINDIET 2002 Survey, which estimated habitual food consumption, dietary supplement use and nutrient intakes using 48-hour recall and two 3-day food records, and an Internet survey of the consumption of fortified foods and dietary supplements. SETTING/PARTICIPANTS: Participants of FINDIET 2002 were 25-64 years old from five areas (n = 2007). Participants of the Internet-based survey (n = 1537) were over 15 years of age from all over the country. RESULTS: If all potentially fortifiable foods were to be fortified with calcium, the proportion of participants with calcium intake below the recommended level (< 800 mg day(-1)) would decrease from 20.3% to 3.0% in men and from 27.8% to 5.6% in women compared with the situation where no foods were fortified. At the same time, the proportion of participants with calcium intake above the tolerable upper intake level (UL, > 2500 mg day(-1)) would increase from 0.6% to 12.7% in men and from 0.1% to 3.8% in women. However, in a probability-based model (11% of all fortifiable foods to be fortified with calcium) the proportion of participants with calcium intake below the recommended level would be 15.7% in men and 23.2% in women. The proportion with intake above the UL in this model would be 1.2% in men and 0.7% in women. CONCLUSIONS: Food fortification would be a relatively effective and safe way to increase the calcium intake of the Finnish adult population.     

Adaptation and evaluation of the National Cancer Institute's Diet History Questionnaire and nutrient database for Canadian populations

BACKGROUND AND OBJECTIVE: Despite assumed similarities in Canadian and US dietary habits, some differences in food availability and nutrient fortification exist. Food-frequency questionnaires designed for the USA may therefore not provide the most accurate estimates of dietary intake in Canadian populations. Hence, we undertook to evaluate and modify the National Cancer Institute's Diet History Questionnaire (DHQ) and nutrient database. METHODS: Of the foods queried on the DHQ, those most likely to differ in nutrient composition were identified. Where possible these foods were matched to comparable foods in the Canadian Nutrient File. Nutrient values were examined and modified to reflect the Canadian content of minerals (calcium, iron, zinc) and vitamins (A, C, D, thiamin, riboflavin, niacin, B6, folate and B12). DHQs completed by 13 181 Alberta Cohort Study participants aged 35-69 years were analysed to estimate nutrient intakes using the original US and modified versions of the DHQ databases. Misclassification of intake for meeting the Dietary Reference Intake (DRI) was determined following analysis with the US nutrient database. RESULTS: Twenty-five per cent of 2411 foods deemed most likely to differ in nutrient profile were subsequently modified for folate, 11% for vitamin D, 10% for calcium and riboflavin, and between 7 and 10% for the remaining nutrients of interest. Misclassification with respect to meeting the DRI varied but was highest for folate (7%) and vitamin A (7%) among men, and for vitamin D (7%) among women over 50 years of age. CONCLUSIOn: Errors in nutrient intake estimates owing to differences in food fortification between the USA and Canada can be reduced in Canadian populations by using nutrient databases that reflect Canadian fortification practices.     

Assessment of Turkish women's knowledge concerning folic acid and prevention of birth defects

OBJECTIVES: In Turkey, the incidence of neural tube defects (NTDs) is 30.1 per 10,000 births. For this reason it seems an important problem for women of childbearing age. Adequate periconceptional consumption of folic acid could prevent NTDs. Most women are unaware of this recommendation. The objectives of this study were to evaluate women' knowledge and beliefs with regard to folic acid, and to estimate the consumption frequency of vitamin supplements periconceptionally and during the first trimester of pregnancy. DESIGN: Eight hundred and eighteen married women who had delivered a live-born infant within the previous 12 months completed the questionnaire. Each subject participated in a 20-minute interview, with the questionnaire comprising multiple-choice statements. A random sample of 10 public health centres was drawn from 27 in three districts in Konya where about 50% of the population lives. RESULTS: Only 22% of subjects had heard or read about folic acid. Thirteen per cent of women indicated knowledge of the direct link between folic acid supplementation and NTD prevention. The knowledge was greatest among 26- to 35-year-olds. Women with a university degree were more likely to have heard about folic acid than were less-educated women. CONCLUSION: The results indicate that further government efforts are needed to inform the population and promote the optimal use of folic acid supplements and folate-enriched foods. It is the responsibility of national authorities to increase health education concerning folic acid and the prevention of NTDs in their countries.     

A quantitative stable-isotope LC-MS method for the determination of folic acid in fortified foods

A stable-isotope liquid chromatography-mass spectrometry (LC-MS) assay was developed for the quantitative determination of folic acid in fortified foods. Folic acid was extracted from food samples into a phosphate buffer, purified on a C-18 Sep-Pak cartridge, and analyzed by LC-MS in the negative ion mode using electrospray ionization. The analyte was quantified using (13)C(5)-folic acid as an internal standard. The coefficient of variation for the precision of the method was 5.6% based on the analysis of four sample replicates. The accuracy of the method was assessed using a standard method of addition of folic acid to a shredded whole-wheat cereal. The quantitative determination of folic acid in this matrix was linear over 1 order of magnitude having a concentration range of 2.4 to 24 microg/g of food (or 0.05 to 0.5 microg of analyte injected into the LC-MS). The overall quantitative efficiency of the method was evaluated using a standard reference material (infant formula SRM 1846). The method was applied to the determination of folic acid in several test samples (fortified breakfast cereals), and the values were in accord with the manufacturer's claim. This method advances a LC-MS technique for the determination of folic acid in fortified foods based on stable-isotope dilution methodology. The specificity of the technique and quantitative accuracy of the method in various food substrates suggests that the method may be adapted for routine analysis in other fortified foods.     

A method for the analysis of natural and synthetic folate in foods

The essentiality of dietary folates for human beings has been known for many years. Over the shorter term, biological activities associated with several human maladies and the attenuation of biomarkers for several chronic diseases also have been assigned to folates. In the United States, these observations have led to the addition of folic acid to several foods and food ingredients (food fortification) and to dietary recommendations that assign biological activity to each of the forms of folate in the food supply. There currently is unavailable a robust, instrumental procedure that will distinguish between naturally occurring food folates and synthetic folic acid as part of the routine analysis of foods. The procedure proposed in this publication is unique in that it uses "off-the-shelf" supplies and instrumentation, to the extent possible, and was developed with "normal" corporate work schedules in mind. This method takes advantage of the tri-enzyme food digestion and folate deconjugation steps but was optimized with a commercially available rat plasma as the source of conjugase. A high-capacity styrene-divinylbenzene-based solid-phase extraction column was identified, and conditions were developed for quantitative recovery of 5-methyltetrahydrofolate and folic acid (FA) with it. The various forms of food folates are separated on a C-18 high-performance liquid chromatography (HPLC) column which is resistant to degradation at low pH. As a result, the mobile phase was simplified to a gradient of low-pH phosphate buffer (pH 2.2) and acetonitrile. Although FA does not exhibit fluorescence, a UV-induced photolysis system was added, which is controlled by the HPLC system, so that an appropriate segment of the HPLC column effluent is subjected to photolytic conditions and, thereby, FA can be measured as a fluorescent product. The application of the system was verified by analyzing several certified reference materials and foods and comparing results with certified values and/or total folate values as determined by microbiological assay.     

Challenges in translating scientific evidence into mandatory food fortification policy: an antipodean case study of the folate-neural tube defect relationship

OBJECTIVE: To identify challenges in translating scientific evidence of a nutrient and health relationship into mandatory food fortification policy. DESIGN: A case study approach was used in which available evidence associated with the folate-neural tube defect relationship was reviewed against the Australia New Zealand Food Regulation Ministerial Council's Policy Guideline for mandatory food fortification. RESULTS: Three particular challenges were identified. The first is knowing when and how to act in the face of scientific uncertainty. The second is knowing how to address the special needs of at-risk individuals without compromising the health and safety of the population as a whole. The third is to ensure that a policy is sufficiently monitored and evaluated. CONCLUSIONS: Despite the availability of compelling evidence of a relationship between a particular nutrient and a health outcome, a definitive policy response may not be apparent. Judgement and interpretation inevitably play significant roles in influencing whether and how authorities translate scientific evidence into mandatory food fortification policy. In relation to the case study, it would be prudent to undertake a risk-benefit analysis of policy alternatives and to implement nutrition education activities to promote folic acid supplement use among the target group. Should mandatory folate fortification be implemented, comprehensive monitoring and evaluation of this policy will be essential to know that it is implemented as planned and does more good than harm. In relation to mandatory food fortification policy-making around the world, ongoing national nutrition surveys are required to complement national policy guidelines.     

Framework for intake simulation of functional ingredients

OBJECTIVE: To create a general framework for the simulation of intakes from mandatory or voluntary fortification, which will make outcomes of simulation studies more comparable and give insight on uncertainties. DESIGN: A general framework was developed based on methods used in already published case studies of mandatory fortification. The framework was extended to be suitable for the simulation of voluntary fortification. Case studies of folic acid fortification were used to illustrate the general framework. RESULTS: The developed framework consists of six steps. First, the definition of the fortification strategy (step 1), followed by the identification of potential carrier products (step 2), and the definition of fortification levels or ranges (step 3). Thereafter, virtual food/supplement composition data are created (step 4) and food/supplement consumption data are required (step 5). Finally, the intake of the functional ingredient from functional foods, other foods and dietary supplements is calculated during the simulation resulting in total habitual intake distributions (step 6). CONCLUSIONS: Simulation of both mandatory and voluntary folic acid fortification in The Netherlands showed that the general framework is applicable. Also with incomplete data or data from different sources, the (habitual) intake distributions can be estimated using assumptions, statistical procedures or probabilistic modelling approaches. It is important that the simulation procedure is described well, so that an insight on uncertainties and knowledge gaps to be filled is given.     

Folate content in commercial white and whole wheat sandwich breads

After the U.S. mandate of folic acid fortification of enriched grain products, a report indicated higher than expected fortification. Limited information is available on folic acid in enriched products. We measured the folate content in 92 sandwich breads (46 white breads and 46 whole wheat breads) in Birmingham, Alabama, during 2001-2003. The mean folate content in white bread declined significantly from 2001 to 2002 or 2003, whereas the decline in folate content in whole wheat bread containing enriched flour was not significant. White bread contained significantly more folate than whole wheat bread containing enriched flour in 2001 and 2003. In 2002 and 2003, >40% of breads made of enriched flour contained <115 microg of folate/100 g and >70% contained <160 microg/100 g. These percentages were markedly higher than those in 2001. Our data suggest that folic acid in breads containing enriched flour declined after 2001 and monitoring of fortification may be necessary.     

Effect of different dosage and administration schedules of folic acid on blood folate levels in a population of Honduran women of reproductive age

BACKGROUND: Observational studies and clinical trials have shown conclusive evidence that periconceptional folic acid supplementation prevents up to 70 % of neural tube defects (NTD). The Honduran government wanted to implement a supplementation programme of folic acid but needed to assess the relative effects of two dosages of folic acid. OBJECTIVE: To determine the effect of two dosages of folic acid on blood folate levels in Honduran female factory workers aged 18 to 49 years. DESIGN: This was a randomized, double-blind control supplementation trial conducted in Choloma, Honduras. A total of 140 eligible women were randomly assigned to two dosage groups and followed up for 12 weeks. One group received a daily dosage of 1 mg folic acid and the other a once weekly dosage of 5 mg. Serum folate and red blood cell folate levels were determined by radioassay at baseline, 6 weeks and 12 weeks. RESULTS: Serum folate levels increased from 6.3 (se 0.2) to 14.9 (se 0.6) ng/ml (P < 0.0001) in women assigned to the 1 mg/d group and from 6.9 (se 0.3) to 10.1 (se 0.4) ng/ml (P < 0.0001) in those assigned to the 5 mg/week group. Red blood cell folate concentrations also increased significantly in both groups, albeit more slowly. Educational level, age and BMI were not associated with the changes in serum and red blood cell folate levels during the supplementation period. However, a differential effect on serum folate levels by dosage group and time was observed. CONCLUSIONS: Although both folate supplementation regimens increased serum and red blood cell folate levels significantly among the women studied, blood folate levels that are considered to be protective of NTD were reached faster with the daily dosage of 1 mg folic acid.     

Comparison of blood folate levels among pregnant Chinese women in areas with high and low prevalence of neural tube defects

OBJECTIVE: To characterise plasma and red-blood-cell (RBC) folate status among pregnant women in an area with an extremely high prevalence of neural tube defects, and to compare them with those of women from a low prevalence area. DESIGN: A cross-sectional survey conducted in 2003. SETTING: One county and one city from each of the high prevalence area and the low prevalence area in China. SUBJECTS: Five hundred and sixty-two women in their first trimester of pregnancy in the high prevalence area and 695 pregnant women in the low prevalence area. RESULTS: Women in the high prevalence area had less than half the plasma and RBC folate concentrations (12.2 and 440.0 nmol l- 1, respectively) of women in the low prevalence area (33.5 and 910.4 nmol l- 1, respectively). In the high prevalence area, 40% of rural women were deficient in RBC folate and 50% were deficient in plasma folate; 20% of urban women were deficient in RBC folate and 30% deficient in plasma folate. In contrast, only 4% (RBC folate) and 6% (plasma folate) of rural women, and 2% (RBC folate) and 1% (plasma folate) of urban women, were folate-deficient in the low prevalence area. Less than 10% of rural and about 26% of urban women in the high prevalence area took folic acid periconceptionally, compared with 70% and 60% of women in the low prevalence area. CONCLUSIONS: Blood folate deficiency is highly prevalent among pregnant women in an area of China with a very high prevalence of neural tube defects.     

Low compliance with recommendations on folic acid use in relation to pregnancy: is there a need for fortification?

OBJECTIVE: As a means to prevent neural tube defects (NTDs), women planning pregnancy in Denmark are recommended to take a dietary supplement of 400 microg folic acid daily during the periconceptional period. We examined compliance with this recommendation in a national survey. DESIGN: Cohort study on pregnant women in Denmark. SETTING: The Danish National Birth Cohort (DNBC). SUBJECTS: From November 2000 to February 2002, 22,000 pregnant women were recruited for DNBC. Use of dietary supplements was recorded at enrollment. Compliance with the recommendation was related to an information campaign that took place during the second half of 2001, and to lifestyle factors provided in a telephone interview by the end of the first trimester of pregnancy. RESULTS: An increase was seen in the proportion of women complying with the recommendation in the study period and this coincided with the information campaign events. However, even at the end of the period, only 22.3% of the women who had planned their pregnancy fully complied with the recommendation. No increase at all was seen in periconceptional folic acid use among women with unplanned pregnancies. Young age, low education and smoking were identified as factors that determined non-compliance. CONCLUSIONS: Alternative and more effective strategies are needed if the Danish population is to benefit fully from the knowledge that folic acid prevents NTDs. Future strategies should not only target vulnerable groups, such as the less educated and the young, but also women who get pregnant without planning this. The only possible way to reach the last group may be through fortification of foods with folic acid.     

The relationship between education and food consumption in the 1995 Australian National Nutrition Survey

OBJECTIVE: To assess the relationship between education and the intake of a variety of individual foods, as well as groups of foods, for Australian men and women in different age groups. DESIGN: Cross-sectional national survey of free-living men and women. SUBJECTS: A sample of 2501 men and 2739 women aged 18 years and over who completed the National Nutrition Survey (NNS) 1995. METHODS: Information about the frequency of consumption of 88 food items was obtained using a food-frequency questionnaire in a nation-wide nutrition survey. Irregular and regular consumers of foods were identified according to whether they consumed individual foods less than or more than once per month. The relationship between single foods and an index of education (no post-school qualifications, vocational, university) was analysed via contingency table chi-square statistics for men and women. Food group variety scores were derived by assigning individual foods to conventional food group taxonomies, and then summing the dichotomised intake scores for individual foods within each food group. Two-way analyses of variance (education by age groups) were performed on food variety scores for men and women, separately. RESULTS: While university-educated men and women consumed many individual foods more regularly than less-educated people, they were less likely to be regular consumers of several meat products. The relationship between education and food consumption was less apparent when individual food scores were aggregated into food group scores. University-educated men and women exhibited higher scores on total food group variety than the other educational groups. CONCLUSIONS: Higher education is associated with the regular consumption of a wider variety of foods. Aggregation of individual food consumption indices into food variety scores may mask the apparent effects of educational background on food consumption.     

Stability of Native Folate and Added Folic Acid in Micronutrient‐Fortified Corn Masa and Tortillas

Degradation of added folic acid and native folates in micronutrient‐fortified corn masa and tortillas was evaluated using masa prepared from either nixtamalized corn flour or fresh nixtamal. Variations in masa pH, masa holding time at an elevated temperature, and iron source failed to show significant differences in folate loss in corn flour masa prepared in the laboratory. Masa was subsequently prepared from fresh nixtamal in a commercial mill in Mexico, and fortified with one of two different micronutrient premixes containing iron, zinc, B‐vitamins, and either unencapsulated or lipid‐encapsulated folic acid. Folate loss in commercial masa increased significantly with prebake masa holding time for both premixes. Unencapsulated folic acid showed a 73% loss after 4 hr of holding, compared to 60% loss for encapsulated. The difference was statistically significant, indicating a protective effect from the lipid coating. No significant differences in folate levels were found between prebake masa and baked tortillas. Holding baked tortillas for up to 12 hr also had no effect on folate levels. Native folate showed no significant losses throughout the process. Results from the commercial tortilla mill indicate that most of the loss in added folic acid occurs during prebake holding of masa, possibly from microbial degradation.     

Perceptions of New Zealand nutrition labels by Māori, Pacific and low-income shoppers

BACKGROUND: In New Zealand the burden of nutrition-related disease is greatest among Māori, Pacific and low-income peoples. Nutrition labels have the potential to promote healthy food choices and eating behaviours. To date, there has been a noticeable lack of research among indigenous peoples, ethnic minorities and low-income populations regarding their perceptions, use and understanding of nutrition labels. Our aim was to evaluate perceptions of New Zealand nutrition labels by Māori, Pacific and low-income peoples and to explore improvements or alternatives to current labelling systems. METHODS: Māori, Samoan and Tongan researchers recruited participants who were regular food shoppers. Six focus groups were conducted which involved 158 people in total: one Māori group, one Samoan, one Tongan, and three low-income groups. RESULTS: Māori, Pacific and low-income New Zealanders rarely use nutrition labels to assist them with their food purchases for a number of reasons, including lack of time to read labels, lack of understanding, shopping habits and relative absence of simple nutrition labels on the low-cost foods they purchase. CONCLUSIONS: Current New Zealand nutrition labels are not meeting the needs of those who need them most. Possible improvements include targeted social marketing and education campaigns, increasing the number of low-cost foods with voluntary nutrition labels, a reduction in the price of 'healthy' food, and consideration of an alternative mandatory nutrition labelling system that uses simple imagery like traffic lights.     

Commercial Evaluation of a Continuous Micronutrient Fortification Process for Nixtamal Tortillas

The corn tortilla plays an integral role in the Mexican diet and is an ideal vehicle for micronutrient fortification. Approximately 60% of corn tortillas in Mexico are produced from nixtamal, with the remainder prepared from masa flour. A process for continuous fortification of nixtamal tortillas was evaluated in two commercial mills in Mexico. A commercial powder dosifier was used to add micronutrient premix containing iron, zinc, folic acid, niacin, riboflavin, and thiamin to nixtamal (1 g/kg) as it was milled. After training and preliminary sampling, mills produced fortified tortillas unassisted for four weeks. Masa flow rates over a four‐day period were 10–12 kg/min in both plants. Premix flow from the dosifier showed good stability, with an average coefficient of variation of 1.6%. Initial results indicated consistency in the fortification process, with significantly increased variation during the four‐week production period. Fortified tortillas had significantly higher levels of all nutrients tested. Micronutrient losses were <11% in all cases except folic acid, which showed an 80% loss. Despite processing losses, fortification resulted in a nearly fivefold increase in folic acid compared with control tortillas. The new fortification process is technically viable and was well received by millers.     

Determination of folate concentrations in pulses by a microbiological method employing trienzyme extraction

Over the past two decades, the role of folate in human nutrition has been of much interest because of its relationship to diseases such as neural tube defects and heart disease. Since 1998, the U.S. Food and Drug Administration has mandated that cereal products be fortified with 140 microg of folic acid/100 g. It is important, therefore, to be able to determine accurately the folate concentrations in cereals and other grains to ensure proper dietary intake of folate. In this study, a microbiological method employing a trienzyme extraction procedure was applied to the analysis of folate in several starchy grain legumes (pulses). Differences in the folate content of dry bean were observed among some market classes but not between cultivars in the same market class. Location had a significant effect on the folate content of lentil and dry pea; cultivar did not. The significant effect of market class, cultivar, and growth environment on the levels of folate in pulses is of particular importance to pulse processors and pulse breeders.     

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.