Food Fortification in a Globalized World

M.G.Venkatesh Mannar, Richard F. Hurrell

• Publisher: Academic Press
• Year: 2018
• ISBN:
  9780128028971
• Topic: Medicine
• Subtopic: Nutrition, Dietics & Bariatrics

Food Fortification in a Globalized World outlines experiences over the past 50 years—and future potential—for the application of food fortification across a variety of foods in the industrialized and developing world. The book captures recent science and applications trends in fortification, including emerging areas such as biofortification, nutraceuticals and new nutrient intake recommendations, standards, policy and regulation. The book proposes a balanced and effective food fortification strategy for nations to adopt. In covering the most technical scientific details in an approachable style, this work is accessible to a range of practitioners in industry, government, NGOs, academia and research.

Food fortification has become an increasingly significant strategy to address gaps in micronutrient intakes in populations with measurable impact in both industrialized and developing countries. While the positive impacts are well recognized there are new concerns in some countries that excessive fortification of foods, outdated nutritional labeling rules and misleading marketing tactics used by food manufacturers may result in young children consuming harmful amounts of some vitamins and minerals.

• Presents the latest science on fortification for the prevention of micronutrient deficiencies
• Includes emerging areas such as biofortification, nutraceuticals and new nutrient intake recommendations, standards, regulations, practices and policies from around the world
• Summarizes evidence of application of food fortification and measured impact on public health
• Discusses how public policy impacts fortification of foods and nutritional deficiencies
• Considers the complex economics of and market for fortified foods

Section VI

Nutrient Wise Review of Evidence and Safety of Fortification

Outline

• Chapter 20 Efficacy and Safety of Iron Fortification
• Chapter 21 Zinc Fortification
• Chapter 22 Efficacy and Safety of Iodine Fortification
• Chapter 23 Global Status of Folic Acid Fortification—Progress and Gaps¹
• Chapter 24 Assessing all the Evidence for Risks and Benefits With Folic Acid Fortification and Supplementation
• Chapter 25 Nutrient-Wise Review of Evidence and Safety of Fortification: Vitamin A
• Chapter 26 Efficacy and Safety of Vitamin B12 Fortification
• Chapter 27 Vitamin D and Calcium

Chapter 20

Efficacy and Safety of Iron Fortification

Richard F. Hurrell, Swiss Federal Institute of Technology, Zurich, Switzerland

Abstract

Iron deficiency affects many women and children in both affluent and developing countries. Perhaps its most serious consequence is impaired motor and mental development in children due to lack of iron to the brain during fetal development and in early childhood. Decreased work capacity in adults also has major economic consequences. The evidence base for efficacious iron fortification has been greatly extended in recent years. This chapter summarizes this knowledge and focuses on the choice of iron compounds in relation to their demonstrated ability to maintain or improve iron status in women and children. Iron absorption studies and efficacy trials made in women and children are reviewed. The most suitable iron compounds for addition to specific foods are suggested based on demonstrated efficacy and the need to cause no unacceptable sensory changes. The recommended fortification levels needed to ensure efficacy take into account the relative bioavailability of the iron compound as measured in humans. Safety is reviewed in relation to the potential for increasing the severity of infections, and increasing the risk of iron overload, cardiovascular disease, and cancer.

Keywords

Iron fortification; iron fortification compounds; efficacy; absorption; iron status; women; children; safety

Chapter Outline

• 20.1 Iron Fortification Compounds With Confirmed Efficacy 196
  • 20.1.1 Defining the Iron Fortification Level 196
  • 20.1.2 Ascorbic Acid 197
  • 20.1.3 Ferrous Sulfate 197
  • 20.1.4 Ferrous Gluconate 198
  • 20.1.5 Ferrous Fumarate 198
  • 20.1.6 Ferric Pyrophosphate 198
  • 20.1.7 Electrolytic Iron 199
  • 20.1.8 Sodium Iron Ethylenediaminetetraacetic Acid 200
  • 20.1.9 Ferrous Bisglycinate 201
• 20.2 Technologically Modified Iron Compounds With Confirmed Efficacy 201
  • 20.2.1 Encapsulated Ferrous Sulfate 201
  • 20.2.2 Encapsulated Ferrous Fumarate 202
  • 20.2.3 Micronized Dispersible Ferric Pyrophosphate SunActive Fe 202
• 20.3 Other Potentially Useful Compounds 202
  • 20.3.1 Ferric Ammonium Citrate 202
  • 20.3.2 Ferrous Lactate 203
  • 20.3.3 Ferric Orthophosphate 203
  • 20.3.4 Ferrous Succinate 203
• 20.4 Current Developments in Iron Fortification 203
  • 20.4.1 Phytase 203
  • 20.4.2 Nano Iron 203
  • 20.4.3 Aspiron 203
• 20.5 Suggested Iron Compounds for Different Food Vehicles 203
  • 20.5.1 Cereal Flours, Bread and Pasta 203
  • 20.5.2 Rice 204
  • 20.5.3 Salt 204
  • 20.5.4 Soy Sauce and Fish Sauce 204
  • 20.5.5 Bouillon Cubes and Spice Mixes 205
  • 20.5.6 Milk Products 205
  • 20.5.7 Beverages 205
  • 20.5.8 Cereal-Based Complementary Foods 205
  • 20.5.9 Micronutrient Powders 205
  • 20.5.10 Chocolate Drink Powders 205
  • 20.5.11 Breakfast Cereals 205
• 20.6 Potential Health Risks of Iron Fortification 205
  • 20.6.1 Infectious Disease 205
  • 20.6.2 Iron Overload 206
  • 20.6.3 Cardiovascular Disease 206
  • 20.6.4 Diabetes Type 2 207
  • 20.6.5 Cancer 207
• 20.7 Balance Between Benefit and Risk 207
• References 207

Iron is essential for hemoglobin, which transports oxygen for energy production, and for a range of key enzymes. These enzymes are essential for normal brain development in the fetus and child, for optimum immune defence, and for efficient energy production. Iron enzymes can be impaired before hemoglobin levels decrease. Iron deficiency (ID), either without anemia or with anemia (iron deficiency anemia (IDA)) is estimated to effect up to 2 billion people, mainly young women and children in both affluent and developing nations (Zimmermann and Hurrell, 2007). An adequate supply of iron is essential for adolescent girls and young women to ensure normal fetal brain development during pregnancy, and for infants and young children to ensure normal brain development during childhood. Brain enzymes need iron for myelinization of nerve fibers, for neurotransmitter metabolism, and for neuronal and oligodendroglial cell migration. Disruption of these processes by ID leads to predictable and consistent structural, electrophysiologic, and behavioral abnormalities both during the period of ID and long after iron repletion. This results in poor motor development and impaired cognitive development in infants and children (Lozoff et al., 2006).

Iron is also needed for efficient thyroid metabolism, and, although iodine deficiency is considered the world’s single greatest cause of preventable mental retardation, it should be remembered that iodine fortification is poorly efficacious for a population with a high prevalence of ID because of the impairment of thyroperoxidase, a heme-dependent enzyme that iodizes the thyroglobulin (Zimmermann and Hurrell, 2007). Another important consequence of ID is decreased energy production, leading to tiredness and decreased work capacity which may have important economic consequences (Haas and Brownlie, 2001). This is due to a downregulation of iron enzymes important for energy metabolism and insufficient oxygen as a result of lower hemoglobin levels when ID is accompanied by anemia (IDA). Other negative effects of the lack of oxygen due to anemia (including the anemias associated with inflammation, infections, and hemoglobinopathies) include other poor pregnancy outcomes such as prematurity, low birth weight, and maternal deaths at childbirth.

Iron fortification of foods can improve iron status in women and children and thus help overcome the negative health consequences of ID. However, as it is technically more difficult to fortify food with iron than to fortify with other micronutrients, it is important to carefully follow iron fortification recommendations. Difficulties include unacceptable color and flavor changes, low iron absorption due to the presence of strong iron absorption inhibitors in cereal and legume foods (Hurrell, 2002), and poor bioavailability of some iron fortification compounds (Hurrell, 1985). Current knowledge however allows most staple foods, infant foods, and commercial foods to be fortified so as to maintain or improve the iron status of the consumer. The evidence base includes many sensory studies, radioisotope iron absorption studies in human adults (Hurrell et al., 1989), stable isotope iron absorption studies in women and children (Davidsson et al., 1994), and efficacy studies in women and children (Hurrell et al., 2010). Iron-fortified foods will maintain adequate iron status and prevent ID, or will decrease the prevalence of ID. They will also maintain hemoglobin levels and prevent IDA, or will decrease anemia when ID is a major cause of the anemia. Iron-fortified foods however will not decrease the prevalence of anemias caused by infections, inflammation, hemoglobinopathies, or other etiologies (Glinz et al., 2015).

The first part of this chapter discusses iron fortification compounds in relation to their reported bioavailability and efficacy in human studies; suggests ways of overcoming iron absorption inhibitors; and recommends the most suitable iron compounds for different food vehicles based on potential sensory changes, human absorption studies and reported efficacy. The second part of the chapter reviews the safety of iron fortification in relation to malaria infection and diarrhea in children in developing countries, to populations with a high prevalence of hemoglobinopathies, and to increasing the risk of cardiovascular disease, type 2 diabetes, and cancer.

20.1 Iron Fortification Compounds With Confirmed Efficacy

The iron fortification compounds with confirmed efficacy fall into four categories. Ferrous sulfate and ferrous gluconate are water-soluble compounds with good bioavailability, but which may cause color and flavor changes in some foods. Ferrous fumarate has good bioavailability but is poorly water soluble, and causes less sensory changes than readily soluble iron compounds. Ferric pyrophosphate (FPP) and electrolytic iron are water insoluble compounds that cause few or no sensory changes but, because they do not completely dissolve in the gastric juice, are only about half as well absorbed as the soluble compounds and ferrous fumarate. Sodium iron ethylenediaminetetraacetic acid (NaFeEDTA) and ferrous bisglycinate (FBG) are soluble iron chelates which may cause sensory changes, but which protect iron from absorption inhibitors. When added to inhibitory foods, such as cereals, legumes, or milk, iron absorption from the ...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• List of Contributors
• Foreword
• Section I: Need and Approach
• Section II: Recommendations and Guidance
• Section III: Delivery Methods
• Section IV: Technical and Business Considerations
• Section V: Fortification Vehicles
• Section VI: Nutrient Wise Review of Evidence and Safety of Fortification
• Section VII: Program Performance Measurement and Improvement
• Section VIII: National Program Case Studies and Lessons Learned
• Section IX: Business Case Studies
• Section X: Future Trends and Strategies
• Index