Micronutrient Enhancement

through Biofortification through Biofortification

Sherry A. Tanumihardjo

Department of Nutritional Sciences

University of Wisconsin-Madison,

Wisconsin, USA

Distribution of 10.9 million deaths among children

less than 5 years old in all developing countries, 2000

Malaria

8%

Measles

5%

Diarrhoea

12%

HIV

4%

ARI

Perinatal

22%

Other

29%

ARI

20%Malnutrition

60%

Current dimensions of major forms of malnutrition

Intra-uterine growth retardation

• 30 million/year

(23.8% of all births)

Protein-energy malnutrition

• 159 million under-5 children

Iodine deficiency disorders

• 740 million

�Low birth weight

�Brain damage

� Increased morbidity &

mortality

� Brain damage

� Blindness• 740 million

Vitamin A deficiency

• 250 million under-5 children

Anaemia including iron deficiency

• 2 billion

Obesity

• >300 million people

WHO/NHD

� Increased morbidity & mortality

� Impaired motor development

�Reduced physical activity

�CVD & Diabetes

� Blindness

� Increased morbidity &

mortality

Functional and storage iron– Hemoglobin (85%) - iron containing pigment in RBCs

– Myoglobin (5%) - holds oxygen in muscle tissue

– Cytochromes - enzymes important in cellular respiration

– Iron sulfur proteins - important in electron transport

Transferrin - iron carrying protein in the blood– Transferrin - iron carrying protein in the blood

– Serum ferritin - iron storing protein also found in

liver, spleen and bone marrow

– Hemosiderin – derived from hemoglobin and can be

reused

– Enzyme cofactor - peroxidase, catalase

– DNA synthesis - ribonucleotide reductase

Symptoms of iron deficiency anemia

• Pallor

• Weakness

• Palpitations

• Reduced work • Weakness

• Fatigue

• Dyspnea

• Reduced work

capacity

• Short attention span

Functions of vitamin A

Ross et al. (2000) Physiol. Rev. 80:1021-1054.

Xerophthalmia classification

• XN Nightblindness

• X1A Conjunctival xerosis

• XB Bitot’s spot

• X1B Bitot’s spot with conjunctival xerosis

• X2 Corneal xerosis• X2 Corneal xerosis

• X3A Corneal ulceration with xerosis

• X3B Keratomalacia

• XF Xerophthalmia fundus

• XS Corneal scars

CAN LEAD TO BLINDNESS!

Examples of eye signs

Bitot’s spots Blindness

The Interim –

High Dose Supplements

Why are we supplementing

women and children?• Vitamin A status is

compromised for both

mothers and infants in

many developing countries.many developing countries.

• Most sources of vitamin A

are derived from fruits and

vegetables and the ββββ-carotene is

perceived to not be available.

Effects of vitamin A supplementation

in populations with vitamin A-deficiency

• Reduced mortality in children <5 years by 23% (meta-analysis of 7 studies)

• Reduced mortality in pregnant women by 40%• Reduced mortality in pregnant women by 40%

• Reduced severity but not incidence of much respiratory and gastrointestinal disease

• Reduced incidence of malarial attacks by 30%

Beaton et al. Geneva: ACC/SCN, 1993.

Shankar et al. Lancet 1999;354:203-09.

West et al. BMJ 1999;318:570-75.

Supplements alone are not enough!

Tanumihardjo, et al., EJCN 2004

Dietary diversification

Teach them how to garden!

Intestinal wall

ββββ-Cabsorbed

Cleaved

Food

ββββ-Ctotal

ββββ-Cfreed

Bioaccessibility = ββββ-Cfreed / ββββ-Ctotal

Bioavailability = ββββ-C / ββββ-C

Tanumihardjo, IJVNR 72: 41, 2002

Retinal

Reduced

Retinol

Bioavailability = ββββ-Cabsorbed / ββββ-Ctotal

Bioconversion = Retinol / ββββ-Cabsorbed

Bioefficacy = Retinol / ββββ-Ctotal

The bottom line…

All things in moderation All things in moderation

except vegetables!

Fortification

Addition of minerals or preformed

vitamin A to commonly consumed

foods, such as salt, sugar, maize

flour, rice and wheat.

Costs of Interventions to Reduce

Micronutrient Malnutrition

Worldwide:

• 500 million vitamin A capsules distributed annually – cost of $500 million

• $200 million public investments in salt • $200 million public investments in salt iodine fortification leveraged $1.5 billion in private industry contributions over a decade

• $2 per person per year for iron fortification of rice x 500 million people x 10 years = $10 billion

Nicaraguan sugar fortification

• Evaluation of baseline liver retinol reserves were

0.57 µµµµmol/g liver, well above deficient (0.07 µµµµmol/g

liver).

• One year after sugar fortification was

implemented, liver reserves increased to 1.2

µµµµmol/g liver. In 9 of 21 children, liver vitamin A

concentrations were >1.05 µµµµmol/g liver.

Biofortification

Greek word “bios” means “life”Greek word “bios” means “life”

Latin word “fortificare” means

“make strong”

MAKE LIFE STRONG!

A new methodology?

1000 years ago

400 years ago

<400 years ago

<30 years ago

2007!!!

Food

insecurity

Poverty

Poverty as it relates to hidden hunger

Hunger

Over-

nutrition

?

Nutrient

deficienciesHidden

hunger

Obesity

Tanumihardjo et al., JADA, 2007

Diets high in staple foods!!!

Advantages of Biofortification

• Targets the poor: eat high levels of food

staples

• Rural-based: complements fortification and

supplementationsupplementation

• Cost-effective: research at a central location can

be multiplied across countries and time

• Sustainable: investments are front-loaded, low

recurrent costs

Interdisciplinary Communication

and Cooperation is Essential

• Plant Breeders

• Molecular Biologists

• Food Technologists

• Human Nutritionists

• Extensionists

• Experts in Food Product Development/Marketing

• Communications

• Economists

Orange-fleshed sweet potato

Vitamin A equivalency factors: Sweet potato: ~13:1

Indian spinach: ~10:1

ββββ-carotene: ~6:1Haskell et al. Am J Clin Nutr

2004

South African Trial Supervised feeding with 1 mg RAE OFSP versus 0 RAE WFSP

0.004

0.0010.0020.0030.0040.0050.006

Change in liver stores of vitamin A

-0.004

-0.006-0.005-0.004-0.003-0.002-0.0010.0000.001

Intervention effect: -0.008 (-0.015, -0.001)

P = 0.0203

Intervention Control

Infants eating sweet potato

0.4

0.6

0.8

Liv

er

vit

am

in A

accu

mu

lati

on

Sweet potato

Sweet potato

Sachets or tablets

?

0

0.2

6 7 8 10 11 12 13

Age of child (mo)

Liv

er

vit

am

in A

accu

mu

lati

on

( µµ µµm

ol/

g)

Sweet potato

Tablets or sachets

Tanumihardjo, Comp. Rev. Food Sci. & Food Safety, 2008;7:373-81.

Sweet potato in Mozambique

• Effectiveness study using an integrated agricultural

and nutrition intervention

• 2 year intervention covering 2 agricultural cycles

• 90% of intervention households produced sweet

potatopotato

• Intervention children (n = 498) ate more sweet

potato and had higher serum retinol than controls

(n = 243)

Low et al. J Nutr. 2007;137:1320-7.

Towards Sustainable Nutrition Improvement

in Rural Mozambique

.

Taste tests are conducted at every adaptive trial harvest

to determine preferences of local consumers.

Towards Sustainable Nutrition Improvement

in Rural Mozambique

.

Sweet potato bread maker making bread at home and selling it at

the market under the name of Golden Bread.

Orange Sweetpotato

in Africa – a Success Story

• Active behavior change

• Agronomic ‘equality’ crucial

• Assistance to understanding and overcoming constraints to adoption crucialovercoming constraints to adoption crucial

• Farmer participation in breeding and varietal selection

• Seeds systems development

• Product and market development

Moving on to “pumpkin nshima”

Bioefficacy of biofortified maize

on vitamin A status

• To determine the bioefficacy of maize

with enhanced ββββ-carotene

• To determine the effect of ββββ-carotene and maize levels on vitamin A status

1.5

2.0

mo

l)

Results: Liver vitamin A was the same between the ββββ-carotene and high-ββββ-carotene maize group.

Bioconversion : ~3 µµµµg ββββ-carotene to 1 µµµµg retinol.

a

0.0

0.5

1.0

Control Maize BC VA

Treatment

Liv

er

VA

(µµ µµ

mo

l)

bb

c

Partnerships and tasks

• ZamSeed grew the maize

• National Food and Nutrition Commission

– Lusaka – coordinating and mobilizing

the community

• Tropical Research and Development • Tropical Research and Development

Center – Ndola – anthropology and

biochemistry

• University of Wisconsin – Madison –

randomization, field coordination,

oversight, unique biochemical markers

Sensitization

• Provincial health office: 2008

– Vitamin A status survey

– Follow-up with efficacy study

• Survey study in 2009• Survey study in 2009

– Identify six study sites

• Provincial health office: 2009

– Provincial permanent secretary office

– District health office

– District developing coordinating committee

(Jan 2010)

Engaging the community

• Facilitator

– Emily Ngulube – retired nurse-midwife

• Meetings with the community, headmen, church • Meetings with the community, headmen, church

leaders and volunteers.

• Social mobilization activities including drama

and open discussions

• Listed villages within the 6 study sites

• Confirm potential child participants in the

villages by household

Hiring nutritionists

Grinding the maize

Setting up kitchens

Cooking the maize

Stirring and stirring….

Cleaning up the mess

Can the maize change

vitamin A status?

Predictions from animal and

human data.

A male child eating maize

0.5

0.6

0.7

0.8

0.9

1

Liv

er

vit

am

in A

ac

cu

mu

lati

on

m

ol/

g) Sugar

0

0.1

0.2

0.3

0.4

0.5

0.5 1 1.5 2 2.5 3 3.5 4 4.5

Age of child (y)

Liv

er

vit

am

in A

ac

cu

mu

lati

on

(µ(µ (µ(µm

ol/

g)

Maize

Supplements

Bioconversion slows

Tanumihardjo, Comp. Rev. Food Sci. & Food Safety, 2008;7:373-81.

Adolescent girl

eating maize

2

3

4

5

tam

in A

ac

cu

mu

lati

on

(µµ µµ

mo

l/g

)

Fortified sugar (high intake)

?

0

1

13 14 15 16 17 18 19

Age of girl (y)

Liv

er

vit

am

in A

ac

cu

mu

lati

on

(

Fortified sugar (low intake)

Biofortified maize (low intake)

Biofortified maize (high intake)

Tanumihardjo, Comp Rev Food Sci & Food Safety, 2008;7:373-81

Visible traits

• Nutrition education becomes important

• Focus on children and expectant mothers

• Social marketing• Social marketing

• Convincing local farmers to grow

biofortified crops

Invisible traits

• Iron in rice in the Philippines

• Zinc in wheat in Pakistan• Zinc in wheat in Pakistan

Milled Dry Rice

As consumed:

400 grams per day x +10 mg/kg Fe =

+4.0 mg/day Fe

Absorbed (10% bioavailability):

+0.4 mg/day = 30% of the+0.4 mg/day = 30% of the

Mean physiological requirement for absorbed Fe

90% retention after boiling:

Requires +11 mg/kg Fe as purchased

Target for Breeders:

2 mg/kg (current average) + 11mg/kg = 13 mg/kg

The Subjects

Religious sisters from 10 convents

5

6

7

8

9

10

Fin

al

bo

dy

iro

n (

mg

/kg

)

Total body iron after nine months of consuming

high-iron (+1.7 mg Fe/dy) or control rice

stratified by 3 levels of baseline body iron

Control

High-iron

p = .036

p = .032

NS

-0.5+0.6

-0.90.0

0

1

2

3

4

5

Fin

al

bo

dy

iro

n (

mg

/kg

)

1 2 3

Body iron at baseline (mg/kg)

p = .036

2.6 6.0 8.7

Least square means controlling for baseline body iron and amount of rice consumed over 9

months. Yellow numbers inside bars reflect changes from baseline value

+0.1+1.2

-0.5

Inquilab Advanced

Pakistan, PeshawarZinc in wheat

Inquilab 91 Advanced Line

High Zn Rice (increases in Fe as well)

How much extra zinc per day?

– Example: Adult women, rural areas

– Intake of 400 g milled, dry rice x

Zinc biofortification

– Intake of 400 g milled, dry rice x

+8 mg/kg Zn =

+3.2 mg Zn/day

– 40% of the Estimated Average

Requirement

Multinutrient approaches

• What if one could add high provitamin A

and zinc to maize?

• Not only would zinc and vitamin A status • Not only would zinc and vitamin A status

be improved but overall function.

• Zinc is involved in vitamin A metabolism.

Vision retinol retinal

Zn

monooxygenase

Digestion ββββ-carotene 2 retinol

Zn

Synergism between vitamin A and zincdehydrogenase

Protein synthesis

Zn retinol binding protein retinol:RBP in blood

(RBP)

Time!

600 years600 years

Thank you for your attention!

Any questions or discussion points?