Tackling Micronutrient Inadequacies in Bangladesh: Is Food Fortification Enough?
The FAO’s 2012 report on food insecurity states that “progress in reducing hunger has been more pronounced than previously believed”. Even so, almost 1 billion people suffer from chronic undernutrition. Most of these people live in developing countries like Bangladesh. Nutrition security in Bangladesh has improved in recent years, according to the fairly recent Demographic and Health Survey, however a large proportion of the population is still affected by undernutrition:
· 35% of ever-married women are food insecure, and 24% are underweight
· 41% of children aged under 5 are stunted (reflects chronic undernourishment)
· There is a high prevalence of breastfeeding (90% at age 2), but introduction of complementary foods is delayed with one third not receiving any complementary food by 6-9 months, therefore being placed at risk of low energy intakes and iron deficiency
· Anemia is found in 51% of children aged 6 months to 5 years, and in 42% of women of childbearing potential
Good nutrition is more than just enough calories and iron, however. Eating the right amounts of all vitamins and essential minerals, as well as protein, fats and carbohydrates, is important for people to be healthy and productive. Arsenault and co-workers found that almost all young children and women had inadequate intakes of calcium, vitamin A, riboflavin, folate, and vitamin B12 in a survey of 480 rural Bangladeshis. This was explained by low food intakes overall, and poor food diversity. Starchy staples such as rice make up the majority of food intakes (85% of the energy for women) and there is poor consumption of nutrient-rich foods such as fruit and vegetables, meat, legumes, nuts and eggs. The average diet in Bangladesh clearly needs improvement if it is to meet the needs of women and young children for energy, macro- and micronutrients.
One option for dietary improvement is the fortification of staple foods. The advantages of a fortification program, if well-designed, is that it is a low-cost method that does not require behavior change for individuals, as we have discussed previously on TalkingNutrition. Leyvraz and co-workers, who are scientists from the Global Alliance for Improved Nutrition, UNICEF, and the International Centre for Diarrhoeal Disease Research, investigated the diets of preschool-aged children, school-aged children, and non-pregnant, non-lactating women aged 15 to 49 years. They calculated current intakes of key nutrients iron, zinc, folate, vitamin A and vitamin B12 for these three population groups based on 7-day semi-quantitative food frequency questionnaires. 841 preschool-aged children, 1428 school-aged children and 1412 women of childbearing potential were included in the survey. The authors also estimated the effects of fortifying the common staple foods maida flour (a type of wheat flour used in foods produced in a bakery or factory), atta flour (used to make wheat flour-based products in the home) and rice with iron, zinc, vitamin B12 and folate, and oil or sugar with vitamin A on overall nutrient intakes.
For all the vitamins and minerals surveyed, Recommended Nutrient Intakes (RNI) were not met by over half the population, with the exception of vitamin A in women of childbearing potential, and vitamin B12 for children - around three quarters met the RNI. There is scope for dietary improvement here.
An important consideration in food fortification is choosing a food type that is consumed by almost everyone, but in quantities that are relatively similar for everyone. The authors found that almost everyone consumed rice, making it the obvious choice for fortification. Even so, rice consumption showed some clear patterns: rural populations consumed more rice than people in urban areas, who were more likely to eat wheat flour-based products such bread. Only around one third of the population consumed sugar. Oil consumption was also higher in urban rather than rural areas.
When looking at the effect of food fortification, rice fortified with zinc, iron, folate and vitamin B12 would make only a modest impact on nutrient intakes. Rice cannot be fortified with micronutrients at the same level as, for example, wheat flour. This is because rice is eaten by the consumer with the rice grain intact. The most effective method of rice fortification involve the manufacture of rice “grains” from extruded rice flour mixed with vitamins and minerals, that are mixed with normal rice in a certain ratio. As de Pee summarizes, there is a maximum level of micronutrients that can be added without producing noticeable changes in the fortified rice “grains”: some studies have found that if the grains look different to normal rice, they may be removed by the consumer from the cooked product. In contrast, wheat flour can be fortified with higher levels of nutrients without having undesirable visual or sensory changes. Even though not all Bangladeshis eat products containing wheat, those who eat less rice tend to eat more wheat. Fortification of both staples will have a complementary effect. Fortification of both wheat products and rice is more favorable than rice alone, and is estimated to improve intakes to meet the needs of a high proportion of all three population groups for vitamin B12 and folate. Oil fortification with vitamin A is also a useful way to improve vitamin A intakes and is likely to have a substantial effect on meeting requirements. However, fortification efforts are not enough to help meet intake requirements for iron and zinc. The authors recommend that an integrated strategy is implemented to improve dietary diversity and provide targeted supplements alongside food fortification for iron and zinc.
Magali Leyvraz, Arnaud Laillou, Sabuktagin Rahman, Tahmeed Ahmed, Ahmed Shafiqur Rahman, Nurul Alam, Santhia Ireen and Dora Panagides. An Assessment of the Potential Impact of Fortification of Staples and Condiments on Micronutrient Intake of Young Children and Women of Reproductive Age in Bangladesh. Nutrients 2015, 7(12), 9960-9971; doi:10.3390/nu7125511
Arsenault JE, Yakes EA, Islam MM, Hossain MB, Ahmed T, Hotz C, Lewis B, Rahman AS, Jamil KM, Brown KH. Very low adequacy of micronutrient intakes by young children and women in rural Bangladesh is primarily explained by low food intake and limited diversity. J Nutr. 2013 Feb;143(2):197-203. doi: 10.3945/jn.112.169524. Epub 2012 Dec 19. http://www.ncbi.nlm.nih.gov/pubmed/23256144
FAO, WFP and IFAD. 2012. The State of Food Insecurity in the World 2012. Economic growth is necessary but not sufficient to accelerate reduction of hunger and malnutrition. Rome, FAO. http://www.fao.org/docrep/016/i3027e/i3027e.pdf
National Institute of Population Research and Training. Bangladesh Demographic and Health Survey 2011. January 2013. http://dhsprogram.com/pubs/pdf/FR265/FR265.pdf
de Pee, S. (2014), Proposing nutrients and nutrient levels for rice fortification. Annals of the New York Academy of Sciences, 1324: 55–66. doi: 10.1111/nyas.12478