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Palmer A.C.,Center for Human Nutrition | Siamusantu W.,National Food and Nutrition Commission | Chileshe J.,Tropical Diseases Research Center | Schulze K.J.,Center for Human Nutrition | And 9 more authors.
American Journal of Clinical Nutrition

Background: Vitamin A deficiency remains a nutritional concern in sub-Saharan Africa. Conventionally bred maize hybrids with high provitamin A carotenoid concentrations may have the potential to improve vitamin A status in maize-consuming populations. Objective: We evaluated the efficacy of regular provitamin A carotenoid-biofortified "orange" maizemeal (∼15 μg β-carotene/g) consumption in improving vitamin A status and reducing vitamin A deficiency in children. Design: This was a cluster-randomized controlled trial in the rural farming district of Mkushi, Zambia. All 4- to 8-y-old children in an ∼400-km2 area were identified and grouped by proximity into clusters of ∼15-25 children. We randomly assigned clusters to 1) orange maizemeal (n = 25), 2) white maizemeal (n = 25), or 3) a parallel, nonintervention group (n = 14). Children in intervention clusters (n = 1024) received 200 g maizemeal for 6 d/wk over 6 mo; the maizemeal was prepared according to standardized recipes and served in cluster-level kitchens. Staff recorded attendance and leftovers. We collected venous blood before and after the intervention to measure serum retinol, β-carotene, C-reactive protein, and α1-acid glycoprotein. Results: Intervention groups were comparable at baseline, and vitamin A status was better than anticipated (12.1% deficient on the basis of serum retinol <0.7 μmol/L). Although attendance at meals did not differ (85%), median daily maize intake was higher in white (154 g/d) than in orange (142 g/d) maizemeal clusters. At follow-up, mean serum β-carotene was 0.14 μmol/L (95% CI: 0.09, 0.20 μmol/L) higher in orange maizemeal clusters (P < 0.001), but mean serum retinol (1.00 ± 0.33 μmol/L overall) and deficiency prevalence (17.1% overall) did not differ between arms. Conclusion: In this marginally nourished population, regular biofortified maizemeal consumption increased serum β-carotene concentrations but did not improve serum retinol. This trial was registered at clinicaltrials.gov as NCT01695148. © 2016 American Society for Nutrition. Source

Fiedler J.L.,International Food Policy Research Institute | Lividini K.,International Food Policy Research Institute | Zulu R.,International Center for Tropical Agriculture | Kabaghe G.,National Food and Nutrition Commission | And 2 more authors.
Food and Nutrition Bulletin

Background. Zambia was a pioneer when it started fortifying sugar with vitamin A in 1998. Micronutrient deficiencies-especially among young children-have changed little over the past decade. In 2008 an initiative to introduce fortified flours was halted when last-hour questions about the program could not be answered. Objective. To provide information about the need, coverage, and impact of alternative fortification portfolio options to help Zambia overcome its fortification impasse. Methods. Using household data from the 2006 Living Conditions Monitoring Survey, apparent micronutrient intake levels and apparent consumption levels of sugar, vegetable oil, wheat flour and maize meal were estimated. The household level data were used to estimate individual intakes by assuming that food was distributed among household members in direct proportion to their share of the household's total adult consumption equivalent. Intake adequacy was measured relative to age- and gender-specific Estimated Average Requirements. Combining information on the industrial structure and estimated fortifiable quantities consumed of each food, and assuming the nutrient content is that specified in official regulations, simulations were conducted of the coverage and impact of 14 fortification portfolios. Results. Maize, the most commonly consumed food, is consumed in a fortifiable form by only 23% of the population. Sugar fortification is estimated to have reduced inadequate intake of vitamin A from 87% to 79%. Introducing oil fortification could reduce the prevalence of inadequate vitamin A intake to 61%, and fortifying roller and breakfast maize meal would further reduce it to 57%, and reduce inadequate iron and zinc intakes by 2.2% and 5.5%, respectively. Implementing WHO flour guidelines would triple the potential iron and zinc impacts. Conclusion. Analysis of LCMS apparent consumption data have helped address important information gaps and provide better understanding of the coverage and impacts of alternative fortification portfolios. © 2013, The Nevin Scrimshaw International Nutrition Foundation. Source

Fiedler J.L.,International Food Policy Research Institute | Lividini K.,International Food Policy Research Institute | Kabaghe G.,National Food and Nutrition Commission | Zulu R.,International Center for Tropical Agriculture | And 4 more authors.
Food and Nutrition Bulletin

Background. Since fortification of sugar with vitamin A was mandated in 1998, Zambia's fortification program has not changed, while the country remains plagued by high rates of micronutrient deficiencies. Objective. To provide evidence-based fortification options with the hope of reinvigorating the Zambian fortification program. Methods. Zambia's 2006 Living Conditions Monitoring Survey is used to estimate the apparent intakes of vitamin A, iron, and zinc, as well as the apparent consumption levels and coverage of four fortification vehicles. Fourteen alternative food fortification portfolios are modeled, and their costs, impacts, average cost-effectiveness, and incremental cost-effectiveness are calculated using three alternative impact measures. Results. Alternative impact measures result in different rank orderings of the portfolios. The most costeffective portfolio is vegetable oil, which has a cost per disability-adjusted life-year (DALY) saved ranging from 12% to 25% of that of sugar, depending on the impact measure used. The public health impact of fortified vegetable oil, however, is relatively modest. Additional criteria beyond cost-effectiveness are introduced and used to rank order the portfolios. The size of the public health impact, the total cost, and the incremental cost-effectiveness of phasing in multiple vehicle portfolios over time are analyzed. Conclusions. Assessing fortification portfolios by measuring changes in the prevalence of inadequate intakes underestimates impact. A more sensitive measure, which also takes into account change in the Estimated Average Requirement (EAR) gap, is provided by a dose-response-based approach to estimating the number of DALYs saved. There exist highly cost-effective fortification intervention portfolios with substantial public health impacts and variable price tags that could help improve Zambians' nutrition status. © 2013, The Nevin Scrimshaw International Nutrition Foundation. Source

Nuss E.T.,University of Wisconsin - Madison | Arscott S.A.,University of Wisconsin - Madison | Bresnahan K.,University of Wisconsin - Madison | Pixley K.V.,Wheat Improvement Center | And 5 more authors.
Food and Nutrition Bulletin

Background. Vitamin A deficiency is associated with poor health outcomes related to reproduction, growth, vision, and immunity. Biofortification of staple crops is a novel strategy for combating vitamin A deficiency in high-risk populations where staple food intakes are high. African populations are proposed beneficiaries of maize (Zea mays) biofortified with provitamin A carotenoids, often called "orange maize"because of its distinctive deep yellow-orange kernels. The color facilitates ready recognition but presents a cultural challenge to maizeconsuming populations, including those in much of Africa, who traditionally eat white varieties. Objective. This study explores the intake patterns of, as well as adaptation to, traditional foods made with provitamin A-biofortified maize compared with white maize in rural Zambian children 3 to 5 years of age (n = 189) during a 3-month feeding trial. Methods. The subjects were fed a breakfast of maize porridge (sweet mush), a lunch of maize nshima (stiff mush) with various side dishes, and an afternoon snack based on a 6-day rotating menu. The trial was conducted in 2010. The orange maize used in the trial came from three different sources. O1 maize was from the 2009 harvest and was stored in a freezer until use in 2010. O2 maize was also from the 2009 harvest and was stored in a cold room until 2010. O3 ("fresh") maize was from the 2010 harvest and was fed immediately after harvest in week 9 of the study and then stored in a freezer until milling for the final four weeks. Results. Consumption of menu items, except snacks, was influenced by week (p < .0084). The intakes of porridge and nshima made with orange maize equaled those of porridge and nshima made with white maize from week 2 onward. The intakes of porridge and nshima prepared from O1 and O2 did not differ, but intakes became significantly higher when meals made from O3 were introduced (p < .014 for porridge and p ≤ .013 for nshima). Conclusions. These results demonstrate quick adaptation to orange maize, a preference for recently harvested maize, and an optimistic outlook for similar adaptation patterns in other biofortified-maize target countries. ©2012, The United Nations University. Source

Fiedler J.L.,International Food Policy Research Institute | Afidra R.,Flour Fortification Initiative | Mugambi G.,Ministry of Public Health and Sanitation | Tehinse J.,Independent Food and Nutrition Consultant | And 7 more authors.
Annals of the New York Academy of Sciences

The economic feasibility of maize flour and maize meal fortification in Kenya, Uganda, and Zambia is assessed using information about the maize milling industry, households' purchases and consumption levels of maize flour, and the incremental cost and estimated price impacts of fortification. Premix costs comprise the overwhelming share of incremental fortification costs and vary by 50% in Kenya and by more than 100% across the three countries. The estimated incremental cost of maize flour fortification per metric ton varies from $3.19 in Zambia to $4.41 in Uganda. Assuming all incremental costs are passed onto the consumer, fortification in Zambia would result in at most a 0.9% increase in the price of maize flour, and would increase annual outlays of the average maize flour-consuming household by 0.2%. The increases for Kenyans and Ugandans would be even less. Although the coverage of maize flour fortification is not likely to be as high as some advocates have predicted, fortification is economically feasible, and would reduce deficiencies of multiple micronutrients, which are significant public health problems in each of these countries. © 2013 New York Academy of Sciences. Source

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