Folate fortification : a case study of public health policy-making

This thesis investigates the use of scientific evidence in the process of making public health policy. A case study located within a food regulation setting is used. The aim is to test theory against this case study. The outcome is a theoretical understanding of the use of scientific evidence in the policy-making process in a food regulation setting. Food regulation can influence food composition and food labelling and thereby affect the population's dietary intake. Frequently there are contested values, beliefs, ideologies and interests among stakeholders regarding the use of food regulation as a policy instrument to effect public health outcomes. The protection of public health and safety, taking into account evidence based practice, is generally employed by food regulators as the priority objective during the policy-making process to adjudicate among the competing expectations of stakeholders. However, this policy objective has not been clearly defined and is vulnerable to interpretation and application. The process by which folate fortification policy was made in Australia, in response to epidemiological evidence of a relationship between folate intake during the periconceptional period and reduced risk of neural tube defects, was analysed as a case study of the policy-making process. The folate fortification policy created a precedent for both food fortification and subsequently health claims policy in Australia. A social constructivist method was used to analyse the case study. The method involved deconstructing the food regulatory system into three levels; decision-making process; procedural; and political environment. Data aligned with each level of analysis was collected from 22 key informant interviews, documentary sources, field notes and surveys of both a random sample of the Australian population's knowledge of folate and use of folic acid-containing supplements (n = 5422), and the implementation of folate fortified food products into stores (n = 60). The insights that emerged from each of the three levels of analysis were assessed iteratively to identify a pattern of interrelationships associated with the policy-making process within the food regulatory system. The identified pattern was interpreted against existing theory to gain a theoretical understanding of the public health policy-making process in this political setting. The central argument of this thesis extends Sabatier and Jenkins-Smith's Advocacy Coalition Framework theory to a food regulation setting. The argument is that within the contemporary political climates of neoliberalism and globalisation, a coalition between corporate interests and the values of scientists with a positivist-reductionist approach to public health research is privileged so as to invoke certain scientific evidence to, in turn, legitimise food regulation policy decisions. The theory will help to inform policy-makers about how and why the public health policy objective in a food regulation setting is interpreted and applied. This will contribute to improving policy practice intended to effect public health outcomes. It is concluded that irrespective of the quantity and quality of the scientific evidence that is being made available, scientific evidence cannot be assumed to speak for itself Policy-making is an inherently political and value-laden process and the potential for politically motivated interpretation and application of otherwise value-neutral scientific evidence can undermine the investment in its generation. From this perspective, evidence based practice, far from liberating policy-making from political influence, can itself become part of the problem rather than the solution. Nevertheless, rational evidence based practice is an ideal to strive for and a series of recommendations is proposed to help make the use of evidence in current food regulation policy processes more transparent and democratic.

Rapid bioassay-guided screening of toxic substances in vegetable oils that shorten the life of SHRSP rats

It has been consistently reported that vegetable oils including canola oil have a life shortening effect in Stroke-Prone Spontaneously Hypertensive Rats (SHRSP) and this toxic effect is not due to the fatty acid composition of the oil. Although it is possible that the phytosterol content or type of phytosterol present in vegetable oils may play some role in the life shortening effect observed in SHRSP rats this is still not completely resolved. Furthermore supercritical CO2 fractionation of canola oil with subsequent testing in SHRSP rats identified safe and toxic fractions however, the compounds responsible for life shortening effect were not characterised. The conventional approach to screen toxic substances in oils using rats takes more than six months and involves large number of animals. In this article we describe how rapid bioassay-guided screening could be used to identify toxic substances derived from vegetable oils and/or processed foods fortified with vegetable oils. The technique incorporates sequential fractionation of oils/processed foods and subsequent treatment of human cell lines that can be used in place of animal studies to determine cytotoxicity of the fractions with structural elucidation of compounds of interest determined via HPLC-MS and GC-MS. The rapid bioassay-guided screening proposed would require two weeks to test multiple fractions from oils, compared with six months if animal experiments were used to screen toxic effects. Fractionation of oil before bio-assay enhances the effectiveness of the detection of active compounds as fractionation increases the relative concentration of minor components.

Improving health with nutritional interventions in residential aged care

In a group of Australian aged care residents, dietary energy and nutrient intakes were generally inadequate, despite sufficient energy being served. Six months of multivitamin supplementation improved nutritional status and bone quality; and six months of fortified milk consumption improved serum 25(OH)D and folate levels, and increased vitamin D and folate intakes.

Cholesterol-lowering effects of plant sterol esters and non-esterified stanols in margarine, butter and low-fat foods

Objectives: To determine the efficacy on plasma cholesterol-lowering of plant sterol esters or non-esterified stanols eaten within low-fat foods as well as margarine.
Design: Randomised, controlled, single-blind study with sterol esters and non-esterified plant stanols provided in breakfast cereal, bread and spreads. Study 1 comprised 12 weeks during which sterol esters (2.4 g) and stanol (2.4 g) -containing foods were eaten during 4 week test periods of cross-over design following a 4 week control food period. In Study 2, in a random order cross-over design, a 50% dairy fat spread with or without 2.4 g sterol esters daily was tested.
Subjects: Hypercholesterolaemic subjects; 22 in study 1 and 15 in study 2.
Main outcome measures: Plasma lipids, plasma sterols, plasma carotenoids and tocopherols.
Results: Study 1¾median LDL cholesterol was reduced by the sterol esters (-13.6%; P<0.001 by ANOVA on ranks; P<0.05 by pairwise comparison) and by stanols (-8.3%; P=0.003, ANOVA and <0.05 pairwise comparison). With sterol esters plasma plant sterol levels rose (35% for sitosterol, 51% for campesterol; P<0.001); plasma lathosterol rose 20% (P=0.03), indicating compensatory increased cholesterol synthesis. With stanols, plasma sitosterol fell 22% (P=0.004), indicating less cholesterol absorption. None of the four carotenoids measured in plasma changed significantly. In study 2, median LDL cholesterol rose 6.5% with dairy spread and fell 12.2% with the sitosterol ester fortified spread (P=0.03 ANOVA and <5% pairwise comparison).
Conclusion: 1. Plant sterol esters and non-esterified stanols, two-thirds of which were incorporated into low-fat foods, contributed effectively to LDL cholesterol lowering, extending the range of potential foods. 2. The LDL cholesterol-raising effect of butter fat could be countered by including sterol esters. 3. Plasma carotenoids and tocopherols were not reduced in this study.

Garden & landscape heritage:a crisis of tangible & intangible comprehension and curatorship

The cultural landscape of George Town, Penang, Malaysia, embraces the historic enclave of George Town as well as a range of other significant colonial vestiges adjacent to the entrépôt. Many of these landscapes cannot be isolated from the énclave as they are integral to and part of its cultural mosaic and character. Perhaps the most important are the Penang Hill hill-station landscape and the 'Waterfall‘ Botanic Gardens. The latter is an under-valued 'garden of the empire‘—a garden that significantly underpinned the development and historical and botanical stature of the Singapore Botanic Gardens.This paper reviews the cultural significance of colonial botanic gardens as they were established around the world during the scientific explosion of the late 1800s. It addresses their position within World Heritage listings, and considers the role, significance and importance of the 'Waterfall‘ Botanic Gardens within this context, within the concept of 'cultural landscapes‘, and critiques its absence from the recent World Heritage Listing of the colonial enclaves of Georgetown and Meleka in Malaysia.

Stabilization of highly unsaturated fatty acids and delivery into foods

Highly unsaturated fatty acids derived from fish or algal oils, particularly EPA and DHA, are in high demand as healthy food ingredients in fortified foods. Due to their oxidative instability most food products incorporate stabilized microencapsulated EPA and DHA oils to avoid negative sensory impact associated with oxidation of these fatty acids. Complex coacervation has been particularly successful in stabilizing fish oil and providing an ingredient with a sensory shelf-life consistent with that of the food product. Overcoming the technical challenges associated with the instability of these oils will help drive growth of the omega-3 fortified healthy food ingredient market.

Food fortification : the evidence, ethics and politics of adding nutrients to food

This research book presents a critical analysis of mandatory food fortification as a technology for protecting and promoting public health. Increasing numbers of foods fortified with novel amounts and combinations of nutrients are being introduced into the food supplies of countries around the world to raise populations’ nutrient intakes. Three topical food fortification case studies representing the different public health rationales for adding nutrients to food were assessed for their public health benefits, risks and ethical considerations: Universal salt iodisation (USI) to help prevent iodine deficiency disorders; mandatory flour fortification with folic acid (MFFFA) to help prevent neural tube defects; and mandatory milk fortification with vitamin D (MMFVD) to help prevent vitamin D deficiency. These assessments found that whereas USI performs strongly as a public health intervention, MFFFA and MMFVD are associated with more risks and less ethical justification than an alternative policy option. Food fortification can be a blunt policy response to complex policy problems. The findings highlight that the primary predictor of a mandatory food fortification policy’s benefits, risks and ethics is its ability to address the underlying cause of the policy problem. The analysis of the policy-making processes for each case study found that certain powerful actors use their influence to determine what counts as evidence in policy processes to privilege food fortification activities over alternative policy options. Policy-making frequently was notable for the low prominence it afforded ethical considerations and its lack of public engagement. Priority activities to help strengthen policy processes and outcomes are suggested.

Profiling national mandatory folic acid fortification policy around the world

Mandatory food fortification “occurs when governments legally oblige food producers to fortify particular foods or categories of foods with specified micronutrients” [1]. Because mandatory food fortification exposes everyone in the population who consumes the fortified food(s) to raised levels of the specified micronutrient, it is one of the most powerful policy instruments available to influence dietary intake and population health outcomes. Many national food regulatory authorities have established policy guidance on mandatory food fortification. From an international perspective, the Codex Alimentarius Commission (Codex) provides principles for the addition of essential nutrients to foods [2]. According to these Codex principles, mandatory food fortification with additional vitamins and minerals is recommended where there is proven public health and nutrition need (Note: these principles are under review at the time of writing).

Corporate social responsibility in professional team sport organisations : towards a theory of decision-making

Research question: 

Is iron and zinc nutrition a concern for vegetarian infants and young children in industrialized countries?

Well-planned vegetarian diets are considered adequate for all stages of the life cycle, despite limited data on the zinc status of vegetarians during early childhood. The bioavailability of iron and zinc in vegetarian diets is poor because of their higher content of absorption inhibitors such as phytate and polyphenols and the absence of flesh foods. Consequently, children as well as adult vegetarians often have lower serum ferritin concentrations than omnivores, which is indicative of reduced iron stores, despite comparable intakes of total iron; hemoglobin differences are small and rarely associated with anemia. However, data on serum zinc concentrations, the recommended biomarker for identifying population groups at elevated risk of zinc deficiency, are sparse and difficult to interpret because recommended collection and analytic procedures have not always been followed. Existing data indicate no differences in serum zinc or growth between young vegetarian and omnivorous children, although there is some evidence of low serum zinc concentrations in vegetarian adolescents. Some vegetarian immigrants from underprivileged households may be predisposed to iron and zinc deficiency because of nondietary factors such as chronic inflammation, parasitic infections, overweight, and genetic hemoglobin disorders. To reduce the risk of deficiency, the content and bioavailability of iron and zinc should be enhanced in vegetarian diets by consumption of fortified cereals and milk, by consumption of leavened whole grains, by soaking dried legumes before cooking and discarding the soaking water, and by replacing tea and coffee at meals with vitamin C-rich drinks, fruit, or vegetables. Additional recommended practices include using fermented soy foods and sprouting at least some of the legumes consumed. Fortified foods can reduce iron deficiency, but whether they can also reduce zinc deficiency is less certain. Supplements may be necessary for vegetarian children following very restricted vegan diets.

Protein-enriched diet, with the use of lean red meat, combined with progressive resistance training enhances lean tissue mass and muscle strength and reduces circulating IL-6 concentrations in elderly women: a cluster randomized controlled trial.

Physical inactivity, inadequate dietary protein, and low-grade systemic inflammation contribute to age-related muscle loss, impaired function, and disability.

(1)H-NMR analysis of the human urinary metabolome in response to an 18-month multi-component exercise program and calcium-vitamin-D3 supplementation in older men

The musculoskeletal benefits of calcium and vitamin-D3 supplementation and exercise have been extensively studied, but the effect on metabolism remains contentious. Urine samples were analyzed by (1)H-NMR spectroscopy from participants recruited for an 18-month, randomized controlled trial of a multi-component exercise program and calcium and vitamin-D3 fortified milk consumption. It was shown previously that no increase in musculoskeletal composition was observed for participants assigned to the calcium and vitamin-D3 intervention, but exercise resulted in increased bone mineral density, total lean body mass, and muscle strength. Retrospective metabolomics analysis of urine samples from patients involved in this study revealed no distinct changes in the urinary metabolome in response to the calcium and vitamin-D3 intervention, but significant changes followed the exercise intervention, notably a reduction in creatinine and an increase in choline, guanidinoacetate, and hypoxanthine (p < 0.001, fold change > 1.5). These metabolites are intrinsically involved in anaerobic ATP synthesis, intracellular buffering, and methyl-balance regulation. The exercise intervention had a marked effect on the urine metabolome and markers of muscle turnover but none of these metabolites were obvious markers of bone turnover. Measurement of specific urinary exercise biomarkers may provide a basis for monitoring performance and metabolic response to exercise regimes.

The microstructure and physicochemical properties of probiotic buffalo yoghurt during fermentation and storage: a comparison with bovine yoghurt

The physicochemical and rheological properties of yoghurt made from unstandardised unhomogenised buffalo milk were investigated during fermentation and 28 days of storage and compared to the properties of yoghurt made from homogenised fortified bovine milk. A number of differences observed in the gel network can be linked to differences in milk composition. The microstructure of buffalo yoghurt, as assessed by confocal laser scanning microscopy (CLSM) and cryo scanning electron microscopy (cryo-SEM), was interrupted by large fat globules and featured more serum pores. These fat globules have a lower surface area and bind less protein than the homogenised fat globules in bovine milk. These microstructural differences likely lead to the higher syneresis observed for buffalo yoghurt with an increase from 17.4 % (w/w) to 19.7 % (w/w) in the weight of whey generated at days 1 and 28 of the storage. The higher concentration of total calcium in buffalo milk resulted in the release of more ionic calcium during fermentation. Gelation was also slower but the strength of the two gels was similar due to similar protein and total solids concentrations. Buffalo yoghurt was more viscous, less able to recover from deformation and less Newtonian than bovine yoghurt with a thixotropy of 3,035 Pa.s-1 measured for buffalo yoghurt at the end of the storage, at least four times higher than the thixotropy of bovine yoghurt. While the titratable acidity, lactose consumption and changes in organic acid concentrations were similar, differences were recorded in the viability of probiotic bacteria with a lower viability of Lactobacillus acidophilus of 5.17 log (CFU/g) recorded for buffalo yoghurt at day 28 of the storage. Our results show that factors other than the total solids content and protein concentration of milk affect the structural properties of yoghurt. They also illustrate the physicochemical reasons why buffalo and bovine yoghurt are reported to have different sensory properties and provide insight into how compositional changes can be used to alter the microstructure and properties of dairy products. © 2013 Springer Science+Business Media New York.

Iron intakes of Australian infants and toddlers: findings from the Melbourne Infant Feeding, Activity and Nutrition Trial (InFANT) Program

Fe deficiency remains the most common nutritional deficiency worldwide and young children are at particular risk. Preventative food-based strategies require knowledge of current intakes, sources of Fe, and factors associated with low Fe intakes; yet few data are available for Australian children under 2 years. This study’s objectives were to determine intakes and food sources of Fe for Australian infants and toddlers and identify non-dietary factors associated with Fe intake. Dietary, anthropometric and socio-demographic data from the Melbourne Infant Feeding, Activity and Nutrition Trial Program were analysed for 485 infants (mean age: 9·1 (sd 1·2) months) and 423 toddlers (mean age: 19·6 (sd 2·6) months) and their mothers. Dietary intakes were assessed via 24-h recalls over 3 non-consecutive days. Prevalence of inadequate Fe intake was estimated using the full probability approach. Associations between potential non-dietary predictors (sex, breast-feeding status, age when introduced to solid foods, maternal age, maternal education, maternal employment status and mother’s country of birth) and Fe intakes were assessed using linear regression. Mean Fe intakes were 9·1 (sd 4·3) mg/d for infants and 6·6 (sd 2·4) mg/d for toddlers. Our results showed that 32·6 % of infants and 18·6 % of toddlers had inadequate Fe intake. Main food sources of Fe were Fe-fortified infant formula and cereals for infants and toddlers, respectively. Female sex and current breast-feeding were negatively associated with infant Fe intakes. Introduction to solid foods at or later than 6 months was negatively associated with Fe intake in toddlers. These data may facilitate food-based interventions to improve Australian children’s Fe intake levels.

Dietary micronutrients and in vivo n-3 LC-PUFA biosynthesis in Atlantic salmon

Aquaculture, and in particular Atlantic salmon culture, is expected to deliver n. -3 long-chain polyunsaturated fatty acid (n. -3 LC-PUFA) rich products. Nevertheless, the availability of n. -3 LC-PUFA rich raw materials for aquafeed is dwindling, and at an ever increasing market price. Thus, there is the need to better understand the in vivo n. -3 LC-PUFA biosynthetic capabilities of cultured fish to enable the possible maximization of dietary 18:3n. -3 (ALA) bioconversion to 20:5n. -3 (EPA) and 22:6n. -3 (DHA). The cofactors and coenzymes involved in this metabolic pathway have so far received limited research attention. In this study, juvenile Atlantic salmon were fed an ALA-rich diet with no, normal, or over-fortified inclusion of those micronutrients reported to be essential cofactors (iron; zinc; magnesium) and coenzymes (riboflavin; biotin; niacin) for the fatty acid elongase and desaturase enzymes. The results showed that reduced dietary inclusion of these micronutrients impaired the normal n. -3 LC-PUFA biosynthetic capabilities of fish, whereas the over fortification did not provide any additional benefit. This study provides new knowledge on micronutrients and lipid metabolism interactions in a commercially important cultured species, and is envisaged to be a useful contribution towards developing more sustainable and commercially viable aquafeed for the future.Statement of relevance. This work is the continuation and extension of a previous study (Lewis et al., 2013, Aquaculture 412/413, 215-222) in which we explored the physiological roles and potential effects of micronutrients on fatty acid metabolism in cultured fish. The present study differed from the previous in the blend of minerals and vitamins used, the species, the fatty acid composition of the test diet, and the inclusion also of a negative control. The results are most interesting, showing that riboflavin (B2), biotin (B7), and niacin (B3), Iron (Fe), Magnesium (Mg) and Zinc (Zn) are all required for proper fatty acid bioconversion, but also that a dietary over-fortification does not translate into proportional improved bioconversion.