Food fortification with multiple micronutrients: impact on h | Figure 1

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Food fortification with multiple micronutrients: impact on health outcomes in general population

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Review question

Does multiple micronutrient fortification improve health?

Background

Vitamins and minerals are important for growth and body functioning. Micronutrient deficiencies are common in many populations, and food fortification is one of the interventions to reduce the burden of micronutrient deficiencies and improve health in the general population. Food fortification involves adding micronutrients to processed foods. There have been studies with various single micronutrient fortification, dual micronutrient fortification and multiple micronutrient fortification, including zinc, iron, selenium, vitamin A, vitamin B complexes, vitamin C and vitamin E. We reviewed the evidence about the impact of food fortification with multiple micronutrients (MMNs) on health in the general population.

Study characteristics

We included 43 studies (48 papers) in 19,585 participants (17,878 children) in this review. The evidence is current to August 2018. Most of the included studies assessed the impact of food fortification with MMN compared to placebo or to no intervention; two studies compared food fortification with MMN to iodised salt and one study compared food fortification with MMN to food fortification with calcium alone. Most of the studies (36 out of 43) targeted children. Twenty studies were conducted in developing countries. Food used for fortification included staple foods, such as rice and flour; dairy products, including milk and yogurt; non‐dairy beverages; biscuits; spreads; and salt. A high proportion of studies were funded by commercial sources (e.g. manufacturers of micronutrients), which can be associated with finding more beneficial effects than independently‐funded studies.

Key results

Food fortification with MMN may reduce anaemia by 32%, iron deficiency anaemia by 72%, micronutrient deficiencies (including iron deficiency by 56%, vitamin A deficiency by 58%, vitamin B2 deficiency by 64%, vitamin B6 deficiency by 91% and vitamin B12 deficiency by 58%). MMN fortification may also improve child growth measured as weight for age and weight for height/length. We are uncertain of the effect of MMN fortification on zinc deficiency and child growth measured as height/length for age. The included studies did not report on any side effects associated with MMN fortification, including deaths and diseases. We are uncertain of the effect of food fortification with MMN compared to iodised salt for iron deficiency anaemia and vitamin A deficiency.

Quality of the evidence

The quality of the evidence was low to very low, due to limitations in the study methods that could introduce a risk of bias, high heterogeneity (variation in the results from study to study), and small sample sizes.

Although the review suggests some positive effects of MMN fortification compared to no intervention, a number of other factors should also be considered. Firstly, there is no information on possible side effects of the MMN fortification. Secondly, we could not perform various subgroup analyses to identify whether MMN fortification is more effective in different population groups, food vehicles, dosage, duration of intervention and geographical region, due to limited number of studies in each subgroup. We performed a subgroup analysis to compare commercial and non‐commercially‐funded studies and did not find a significant difference between their results, although we remain cautious about these findings. Our results are uncertain, due to the low quality of the evidence.

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\ \ Why do we need iron in our diet?\ Iron is an essential mineral found in every cell of the body. It is needed to make haemoglobin, the oxygen‐carrying protein in the blood. Iron molecules in haemoglobin bind to oxygen and carry it from the lungs to all the cells and tissues in the body. Low levels of haemoglobin means the body does not get enough oxygen.\ Anaemia develops when haemoglobin levels in the blood fall too low. Symptoms of anaemia include: tiredness and lack of energy, getting out of breath quickly, pale skin and a greater susceptibility to infections.\ Low haemoglobin levels can be caused by blood loss, pregnancy or not eating enough foods containing iron (iron‐deficiency anaemia). Iron‐deficiency anaemia may be treated by taking iron tablets or eating foods rich in iron.\ Fortified foods\ Adding micronutrients (vitamins and minerals) to foods, whether those micronutrients were originally present or not, is called fortification. Fortifying foods is one way to improve nutrition in a population.\ People living in low‐income countries may not have enough iron in their diet, and may be at risk of anaemia. Adding iron and other nutrients to foods routinely eaten in large quantities, such as flour, is thought to help prevent iron‐deficiency anaemia.\ Why we did this Cochrane Review\ We wanted to find out how adding iron, and other minerals and vitamins, to wheat flour affected the blood iron levels of the general population, and whether fewer people developed anaemia or other health conditions. We also wanted to know if adding iron to wheat flour caused any unwanted effects.\ What did we do?\ We searched for studies that investigated eating any types of food made with wheat flour containing added iron, or foods made with wheat flour without added iron. We then compared the studies with each other, to find out the effects of adding iron to wheat flour on people's health and the levels of iron and haemoglobin in their blood.\ Search date: we included evidence published up to 21 July 2020.\ What we found\ We found 10 studies in 3319 people (aged 2 years and older). The studies lasted from 3 months to 24 months, and took place in Bangladesh, Brazil, India, Kuwait, the Philippines, Sri Lanka and South Africa.\ The studies looked at the effects of:\ · wheat flour containing added iron (with or without other minerals and vitamins) compared with wheat flour without added iron (but with the same other minerals and vitamins);\ · wheat flour containing added iron and other minerals and vitamins compared with wheat flour without any added minerals or vitamins.\ The wheat flours used in the studies contained different amounts of iron: from under 40 mg/kg to over 60 mg/kg.\ We were interested in:\ · how many people had anaemia (defined by low haemoglobin levels);\ · how many people had low levels of iron in their blood (iron deficiency; tested using a biomarker);\ · haemoglobin concentrations in people's blood;\ · how many children had diarrhoea or respiratory infections;\ · how many children died (of any cause);\ · signs of infection or inflammation (the body's response to injury) in children (by testing a biomarker in the blood); and\ · any unwanted effects.\ Most studies had multiple sources of funding; some were partly funded by companies involved in the food, chemical or pharmaceutical industries.\ What are the results of our review?\ Compared with flour without added iron (but with other minerals and vitamins)\ Flour containing added iron (with or without other minerals and vitamins):\ · may reduce anaemia, by 27% (evidence from 5 studies, 2315 people); and\ · probably makes no difference to children's risk of infection or inflammation (2 studies, 558 children).\ It was unclear how flour with added iron affected iron deficiency (3 studies, 748 people), or haemoglobin levels (8 studies, 2831 people).\ Compared with flour without any added minerals or vitamins\ Flour containing added iron (with other minerals and vitamins) probably reduced iron deficiency (3 studies, 382 people). 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\ \ Review question\ We reviewed the evidence for effects of nutrition education about appropriate feeding practices during weaning on growth and development in children born at term gestation.\ Background\ Around the world, over 150 million children are undernourished and over 42 million are overweight and obese. Providing families with appropriate education about feeding practices during weaning may help to optimise nutrition while helping to protect children who are at risk of undernutrition, as well as those susceptible to being overweight and obese.\ Study characteristics\ We examined research published up to December 2019 and found 21 clinical trials recruiting 14,241 babies. The nutrition education provided in all included studies, whereby analysis could be pooled together, was aimed at reducing the risk of undernutrition in childhood. Five studies were undertaken in high‐income countries, but the findings reported could not be included and pooled together in this review.\ Key results\ We found that giving nutrition education about appropriate feeding practices during weaning to families in low‐ to moderate‐income settings may improve weight and height at 12 months of age. We are very uncertain about the effects of nutrition education on children's development and risk of anaemia at one year of age, as only two studies reported each of these outcomes. Therefore, these results are described only in the text. We did not find any studies that assessed the effects of nutrition education on children's risk of overweight and obesity and reported outcomes that could be pooled together in this review.\ Certainty of evidence\ The certainty of evidence for the reduction in risk of childhood undernutrition with nutrition education is low to moderate at best due to limitations in study design and differences among the studies included in our review. The amount of improvement in growth noted is small and of unclear clinical significance. More long‐term studies are needed to see if this improvement continues into later life, leading to bigger improvements. We rated the certainty of evidence for other outcomes included in this study as low due to the limited number of included studies.\ Further research is needed to determine whether nutrition education can reduce risks of overnutrition and obesity in children.](https://app.figure1.com/case-detail/55900c0f-5f9b-4611-8e80-bce5bee94a3d)

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