A National Food Fortification Program is shortly to be implemented in South Africa. Gary Klugman replies to issues raised in the article by the Micronutrient Initiative Advisors, based on their comments to the article published by Science In Africa (January 2002), " Addressing Malnutrition In South Africa ".
" In The Meantime, Fortification Delayed Means Nutrition Denied "
This would be true if the fortification projected would result in unquestionable benefit for the population and to ensure control of their nutrient deficiencies. But, as the proposed fortification program is currently presented, this is not the case. The core of the argument is based precisely in the belief, that fortifying a staple food with the recommended compounds, that have never been demonstrated in maize flour, to be effective in addressing the known nutrient deficiencies, is meaningless, ineffective and misleading.
Quality Of Foods
The argument of quality of food becomes important only when enough food is ingested. The Micronutrient Initiative Advisors, have contradicted their own recommendations for nutrient dosage values to be added to maize flour, as they concur, that in particular, the poor children of South Africa, rely almost exclusively on maize porridge for their nutritional needs, and the disproportionate dependency on maize, hence, if the problem of a population is lack of food, to talk about quality is superfluous. In addition the Micronutrient Initiative Advisors point out the high consumption of maize flour, that is almost pure starch and contributes very little in terms of nutrients being only a source of energy. With this extremely poor diet, a fortification program has to focus on providing all the needed nutrients and in the needed amounts to cover the nutritional daily requirements of the population, and not only to add a small amount of nutrients, that does not make the diet nutritionally sufficient, but only marginally better?. The definition of a food fortification program is as follows; Fortification means the addition of one or more nutrients to a food whether or not it is normally contained in the food for the purpose of preventing or correcting a demonstrated deficiency of one or more nutrients in the population or specific population groups by the relevant authority (1).
Restoration of Minerals and Vitamins lost in processing
Maize flour is prepared by refining process, and the majority of the maize flour consumed is de-germed. The germ contains the proteins and the balance is almost pure starch. In a nutrient deficient population, to only restore the lost mineral and vitamin values from processing and refining of maize, (mainly white maize in South Africa) does not contribute significantly to the improvement of the nutrient deficient sector of the population, hence they will remain deficient. Maize flour IS NOT sufficient to make a population nutritionally healthy.
Can Vitamin A RDA Be Achieved
According to the National Food Consumption Survey, there is a deficient intake of vitamin A, and the fortification program had to be designed to fill the void in relation to the mean need of vitamin A intake of the population (RDA). According to Table 1, of the Micronutrient Initiative reply, 6.4 I.U.s' of vitamin A per gram of dry maize flour is added and they assume, contrary to their own data, that there is a final activity of vitamin A in the reconstituted porridge of 60% of the added dose.
The argument, that 47% of the R.D.A. for children 1 - 3 years old is provided in the fortified porridge, only has meaning if that amount is enough to cover the daily need of the vitamin A, plus a significant extra amount to fill the deficit. Thus in this case to state that via the proposed fortification process, 47% of the R.D.A. is been added, does not have any meaning. Because there is a vitamin A deficiency, because one would like to correct the deficiency, because there is a daily need of the vitamin A, that has to be ingested, because the fortification level has to include the daily need, plus the amount needed to correct the deficiency, to state that the proposed program covers 47% of the R.D.A. does not have the significance that the Micronutrient Initiative Advisors wish to imply. The fortified food should ensure, that the daily intake of vitamin A of the population is sufficient to fulfill all needs. If not, the measure would be a simple ineffective palliative, but not a solution to the problem.
Since vitamin A will be added to cereal flours, that are also fortified with reduced iron (of any kind), where is the data that shows that vitamin A is stable in the presence of iron particles? Available literature shows that in the presence of inorganic iron the stability of vitamin A is drastically reduced (2).
The Micronutrient Initiative Advisors state that there is a projected improvement of vitamin A status of South African children, this is wrong, immoral and misleading. Where is the scientifically supported and published evidence? Where in the world has such a program using the same recommended compounds been proven to be successful? Have the Micronutrient Initiative Advisors taken in to account that vitamin A is process dependent and that the reconstitution of maize flour to porridge can vary from 20 minutes to ± 3 hours of cooking on extreme heat, depending on the custom of the population? Thus the 40% vitamin A losses advocated is not based on any scientific evaluations and industry is condemned to pay for these mistakes (experiments carried out at the CSIR, Division Of Food Science And Technology, showed losses of vitamin A when maize porridge was cooked for 25 minutes to be in the order of 97 - 100%, these results were deemed to be flawed and have not been used for the design of the proposed national food fortification program).
The authors in addition state " The fortified maize will go a long way to achieve vitamin A sufficiency, especially when combined with vitamin A from other sources? ", and yet the same authors are unanimous in their conclusions, " That many South African children, particularly the poor, rely almost exclusively on maize porridge for their nutrition? ". A vast majority of the South African population can not afford the luxury of dietary diversification.
Selection of Iron
Inert elemental iron powders are often collectively referred to as " Reduced Iron " and are widely used as fortificants in cereal flours. These iron powders however, are manufactured by 5 different processes, of which electrolytic, is one manufacturing process. Most people have now come to realize, that the reduced iron, traditionally used to fortify cereal flours is not absorbed, (3) on the other hand for the proposed national fortification program in South Africa, the Micronutrient Initiative Advisors, recommendation is " ELECTROLYTIC REDUCED IRON ", and the authors claim to have obtained a good absorption, but the information they quote, Table 2, does not include maize flour, and that is the subject of this discussion. The information the authors quote refers to the supposed use of electrolytic iron in, wheat/milk cereal, wheat bread, plus ascorbic acid (ascorbic acid is a promoter of iron and is not recommended in the proposed National Food Fortification Program) but, there is absolutely no mention on tests conducted on maize flour. The original publications could not be found and it would be interesting to note what procedure was used to develop a radioactive label of the electrolytic iron, and if the authors have any proof whatsoever, that the process does not change the characteristics of the iron particles (it would be appreciated if the authors could advance copies of these publications).
If the electrolytic iron is absorbed 50% of the absorption of Ferrous Sulphate, then the figures presented do not show this relationship. There are a number of issues that have to be answered and not only avoided. For example, what IS the actual absorption of electrolytic iron of a defined particle size in maize porridge? Where have the results of the investigations been published? How many countries have tested and corroborated that the iron particles are indeed absorbed? Where is the data that shows that the absorption of electrolytic iron is regulated by the iron reserves of the body, to avoid any possibility of iron overload? Where are the publications showing in an unquestionable manner, that the use of electrolytic reduced iron (or any other reduced iron) has resulted in the control of Iron Deficiency and Iron Deficiency Anaemia in any country in the world? Where is the data proving that electrolytic reduced iron is better absorbed than other reduced iron compounds of the same particle size? All these questions have to be answered by the Micronutrient Initiative Advisors, insisting on the use of iron particles for flour fortification in South Africa.
Bioavailability of Electrolytic Iron
The Micronutrient Initiative Advisors, in their reply, try and explain the poor absorption of electrolytic reduced iron with the argument of the small amount of absorbed iron that is needed daily, (4) but this argument again is at fault because it is misleading. For example the < 2% absorption of Ferrous Sulphate in maize porridge as reported by Bovell - Benjamin et. al (5) and if the calculations as suggested could really be applied, that would imply absorption of the electrolytic reduced iron of only 2 x 0.5 = 1%, which is very poor, and a serving size of 200g dry maize flour contains 7.4mg Fe (for the sake of this calculation we will accept that the 7.4mg Fe is elemental) the amount of absorbed electrolytic reduced iron upon consumption of 500g maize porridge, will be 0.074mg Fe. Regardless, this is pure speculation, and again, it would be only fair to insist on published scientific peer reviewed data on the true bioavailability of electrolytic reduced iron, with a particle size of 45 micrometers in diameter, in a high phytate food, such as maize porridge, to be provided by the Micronutrient Initiative Advisors to the South African public and the South African Department of Health. Publications that support the poor bioavailaility of Reduced Iron Compounds with a particle size of < 10 micrometers in diameter are (6) (7) (8) (9).
For the record, I stated in my article in Science In Africa (January 2002), that the reduced iron IS electrolyticaly manufactured and the South African Department of Health have recommended that the particle size be 45 micrometers in diameter. (This is the only commercial grade electrolytic reduced iron available in the market at a cost affordable price. If the particle size of the electrolytic reduced iron is < 10 micrometers in diameter, industry could not afford to utilize it as a fortificant, it is cost prohibitive, and all studies carried out on reduced iron (6) (7) (8) (9), used particle sizes < 10 micrometers in diameter)
Fortification lessons to be borrowed from other countries
The quoted success in North and South America is not true. Where is the published evidence for this? If any evidence does exist, did the investigators use the same compounds of the same dosage levels and sizes as they propose to use in South Africa? Have the Micronutrient Initiative Advisors any data on metal to metal interactions? What is the bioavailability of ZnO?. Where is the data showing that there is no mutual interference for absorption of these metals? The available data indicates that interference occurs.
Vitamin A fortification in sugar is a huge success in addressing vitamin A deficiency, Guatemala, El Salvador etc. Venezuela fortify wheat and maize flour with Ferrous Fumarate, this resulted in a decline in ID/IDA and only use reduced iron to top up the difference of elemental content as specified by local law. Currently, in Central America, recognition is now been given to reconsider over 50 years of failure of iron fortification in cereal flours with reduced iron compounds and more bioavailable iron compounds are being sought to address the increase in ID/IDA, which is increasing beyond the population growth. (and it is mandatory to fortify all cereal flours with iron in these countries).
In conclusion, it must be clearly stated that the nutritional needs of South African children and their children to be, must not be handicapped through the lack of delivery of a successful national food fortification program and all parties concerned, that have a true desire to address poverty and malnutrition, must embrace the knowledge that has been bestowed upon them, share information and continuously exchange information on food and nutrition, borrow lessons where we can and implement as many strategies possible and feasible, that will allow South African and African children to take their rightful place in the International Community.
Gary Klugman E-mail
(W) 021 9102780 (C) 083 644 0355