Salt as a novel vehicle for multiple micronutrient fortification
Micronutrient fortification of a staple food or condiment can be an effective strategy for improving the micronutrient status of a population, as the approach is cost-effective, utilises existing delivery systems, can deliver multiple micronutrients simultaneously, and does not require behaviour change by the population.
Salt is an attractive vehicle for multiple micronutrient fortification in India, as it is universally consumed in fairly consistent amounts. India already has excellent coverage of iodized salt and has recently scaled up the distribution of salt fortified with iodine and iron (double-fortified salt).
Extensive research conducted in various settings has shown that double-fortified salt significantly improves iron status in nutritionally vulnerable groups. With new technology developed by the University of Toronto, it is now possible to fortify salt with multiple micronutrients, including zinc, vitamin B12, and folic acid, in addition to iron and iodine.
While salt fortified with encapsulated ferrous fumarate is already being produced at scale and extensively consumed by large populations in India, the planned study proposes to conduct a head-to-head comparison with ferric pyrophosphate likely in combination with citric acid and trisodium citrate (to enhance iron absorption) in an encapsulated medium that is under development and test whether sensory qualities could be improved further.
Plan for the study
The study will be conducted in two phases. Phase 1 will include formative research involving a dietary assessment to ascertain habitual salt intake and dietary intake of micronutrients; qualitative research to understand salt procurement, storage, and utilization practices; as well as sensory and acceptability testing of the quintuply-fortified salts.
Phase 2 will be a double-blind, randomised controlled efficacy trial where 750 women of reproductive age will be randomised to 1 of 3 groups: 1) quintuply fortified salt with iron in the form of encapsulated ferrous fumarate; 2) quintuply fortified salt with iron in the form of ferric pyrophosphate; and 3) iodised salt. In brief, participating women will be provided with the assigned study salt on a monthly basis for 12 months and blood samples will be taken at baseline, 6 months, and 12 months. The primary outcome will be micronutrient status as measured by the change in biomarkers of zinc, iron, folate, vitamin B12 and iodine status. Secondary outcomes to be assessed include DNA damage, essential fatty metabolism and cognition.
If proven efficacious, MFS has the potential not only to improve the micronutrient status of WRA, but also lead to improved perinatal outcomes, and better micronutrient status in their offspring. Together with our collaborators, IZiNCG is excited to initiate this study!
Collaborators: PGIMER, Haryana State Government, SWACH Foundation, WHO Southeast Asia, the University of Toronto, Tata Trusts/ The India Nutrition Initiative, ETH Zürich, JVS Foods, St. John’s Research Institute, University of Colorado Denver, University of California Davis, Eurofins, University of Otago, University of Nottingham, VitMin laboratory.
Last edited 24.03.2020.
Read more:
Strategies for promoting zinc nutrition
Zinc supplementation during pregnancy
Zinc Fortification Task Force