fortification of milk for improving nutrition and immunity
TRANSCRIPT
Ambrish Mithal MD, DM
Chairman, Endocrinology and Diabetes
MAX Healthcare- Pan Max
Member- Governing Body NHA
President, AIIMS, Gorakhpur
Fortification of milk for improving
Nutrition and immunity:
The Vitamin D Story
Association between Vitamin D deficiency and increased risk of
community acquired pneumonia
Vitamin D supplementation was safe and protected
against respiratory tract infections overall
Vitamin D status in adults
(>18 years)
Wahl et al, Arch Osteoporos. 2012 Dec;7(1-2):155-72.
Reasons for widespread deficiency
– Latitude, season, time of the day
– Cloud cover and atmospheric pollution
– Time spent outdoors
– Customary dress and sunscreen use
– Skin pigmentation and age
Nutrition Reviews® Vol. 66(Suppl. 2):S153–S164
Sunlight as a source in India(Marwah, Sethuraman et al, 2015, 2016)
• Regional and seasonal variations+
• Northeast- lowest UV Index with no seasonal
variation
• Very poor synthesis in cities
• Children- +4 ng/ml to -4 ng/ml with half an hour
exposure of 15-30% body surface area- depending
on season.
• Perhaps manual construction workers, security
forces may get adequate D through sunlight
Delhi 70-94%
Tirupati 45-82%
Lucknow75-90%
Hyderabad 34-52%
Punjab 50%
J & K 53-83%
Mumbai 88%
Kolkata 92%
States
Vitamin D deficiency at blood level (< 20 g/dL)
% population eating < 50% of required amount of Vit. A rich foods
Kerala 79.4 91.8
Tamil Nadu 48.8 81.9
Karnataka 52.1 90.4
AP /Telangana 61.5 92.9
Maharashtra 54.7 88.8
MP 88.0 87.4
Orissa 57.7 77.5
West Bengal 61.2 80.6
Pooled 61.8 86.3
India has a very high burden of vitamin A & D deficiencies, impacting all
Vitamin A and D Deficiency in India: NIN
Serum 25 (OH)D levels before and after
vitamin D fortified milk in Delhi children
Group (All
Subjects)
N S.25 (OH) D
level at
baseline
S.25 (OH) D
following
fortification
Group A 237 11.74±5.23 10.83±5.24
Group B 243 11.42±5.24 22.87±6.75*
Group C 233 11.94±5.62 27.67±8.47*
Total 713 11.69±5.36 20.44±9.88*
Group A—no fortification, group B—received milk fortified with 600 IU, group C—received milk fortified with 1,000 IU
R. Khadgawat ; Osteoporos Int; 2013
NFHS-4 for Year 2015-16 and CNNS-2016-17 Factsheet Data
Nutrition & Health Indicators (NFHS-4) in %
All India
Rajasthan Bihar AP Kerala
Underweight (< 5 years) (NFHS-4)
36 37 43.9 31.9 16.1
Stunted (<5 years) (NFHS-4)
38 39 48.3 31.4 19.7
Under 5 mortality (NFHS-4)
50.0 51 58 41 7
Prevalence of vitamin A deficiency in children 5-9 years (CNNS)
21.5 1.0 28.3 22.8 26.5
Prevalence of vitamin A deficiency in children 10-19 years (CNNS)
15.6 1.9 21.9 13.1 13.2
Fortification of edible oil and milk since 2012, MAY HAVE brought down the levels of vitamin A deficiency in children (CNNS 2016-17) in Rajasthan.
IOF – ANZBMS - 2011
Mass fortification
Target fortification
Market-driven fortification
IOF – ANZBMS - 2011
1. Milk and other dairy products:
including dried milk powder and
evaporated milk. Yogurt…
2. Margarine (in EU, 30% of the RDI for
vitamin D comes from margarine)
3. Orange juice, cereals; bread,
mushrooms also work! (AJCN-2010)
IOF – ANZBMS - 2011
Fortification studies in schoolgirls- Beijing
2 year :
Group 1: Ca fortified milk
(330 mg Ca)
Group 2: Ca fortified milk + 8 g VitD
Group 3: Control
Post supplementation 25(OH)D:
Group 1: 17.9 ± 9 nmol/L
Group 2: 47.6 ± 23.4 nmol/L
Group 3: 19.4 ± 10.2 nmol/L
Fraser, 2006
IOF – ANZBMS - 2011
Safety limit
Technological limit
Cost limit
IOF – ANZBMS - 2011
The way forward
• Awareness regarding sunlight
exposure
• Supplementation for vulnerable
groups
• Fortification: Fraught with
challenges- an idea whose time has
come