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ARS Home » Pacific West Area » Davis, California » Western Human Nutrition Research Center » Diet, Microbiome and Immunity Research » Research » Publications at this Location » Publication #391454
Research Project: Impact of Diet on Intestinal Microbiota, Gut Health and Immune Function

Location: Diet, Microbiome and Immunity Research

Title: Simulated impact of vitamin A-fortified sugar on dietary adequacy and association of usual sugar intake with plasma and breast milk retinol among lactating Zambian women

Author
item HAILE, DEMEWOZ - University Of California, Davis
item ENGLE-STONE, REINA - University Of California, Davis
item Caswell, Bess
item LUO, HANQI - Emory University
item DODD, KEVIN - National Institutes Of Health (NIH)
item ARNOLD, CHARLES - University Of California, Davis
item JOBARTEH, MODOU - Imperial College
item GREEN, MATTHEW - Johns Hopkins School Of Public Health
item CHIPILI, MACKFORD - Johns Hopkins School Of Public Health
item HASKELL, MARJORIE - University Of California, Davis
item PALMER, AMANDA - Johns Hopkins School Of Public Health

Submitted to: Maternal and Child Nutrition
Publication Type: Peer Reviewed Journal
Publication Acceptance Date: 7/9/2025
Publication Date: 8/6/2025
Citation: Haile, D., Engle-Stone, R., Caswell, B.L., Luo, H., Dodd, K.W., Arnold, C.D., Jobarteh, M., Green, M., Chipili, M., Haskell, M.J., Palmer, A.C. 2025. Simulated impact of vitamin A-fortified sugar on dietary adequacy and association of usual sugar intake with plasma and breast milk retinol among lactating Zambian women. Maternal and Child Nutrition. https://doi.org/10.1111/mcn.70077.
DOI: https://doi.org/10.1111/mcn.70077

Interpretive Summary: Women who are breastfeeding have high vitamin A requirements because of the need to provide adequate vitamin A for their infants. A mother consuming insufficient amounts of vitamin A may produce breast milk that does not contain enough vitamin A for the infant. Mothers in low- and middle-income countries may be at high risk for inadequate vitamin A intake because they consume few animal source foods, and most of their vitamin A comes from carotenoids in fruits and vegetables that can be converted to vitamin A in the body. Several countries now require products such as sugar or cooking oil to be fortified with vitamin A in order to prevent vitamin A deficiency. Since 1998, Zambia has required manufacturers to fortify sugar with vitamin A. However, several factors such as the fortification levels used in manufacturing, market reach of fortified sugar and the extent of vitamin A insufficiency in the population may limit the impact of this policy on vitamin A status among vulnerable groups such as breastfeeding mothers. This study described the vitamin A and sugar intakes of breastfeeding mothers in Mkushi, Zambia by analyzing the foods and drinks they reported consuming over three days. If sugar were not fortified, the prevalence of vitamin A inadequacy among the mothers would be 83%. Fortifying sugar at concentrations of 3.1 mg vitamin A per kg sugar (mg/kg), 8.8 mg/kg, 10 mg/kg and 15 mg/kg would reduce the prevalence of vitamin A inadequacy by 7, 24, 30 or 47 percentage points, respectively. The mother’s current usual sugar intakes were not associated with the amount of vitamin A in their blood (as plasma retinol concentration) or in their breast milk (breast milk retinol concentration). These results show that sugar fortification has the potential to reduce vitamin A inadequacy. However, even if the target fortification level of 10 mg/kg were achieved, sugar fortification alone is unlikely to eliminate vitamin A inadequacy among breastfeeding women in Zambia

Technical Abstract: Background Large-scale food fortification programs are a cost-effective strategy to increase vitamin A (VA) intake. Zambia has implemented mandatory sugar fortification with VA, however the contribution of VA-fortified sugar to vitamin A intakes and status has not been directly assessed. Objectives We modeled the contribution of VA-fortified sugar to dietary VA adequacy and examined associations between dietary intakes and VA status among lactating women. Methods We conducted three repeated 24-h dietary recalls with 243 lactating women as part of baseline activities for a randomized controlled trial of biofortified maize in Mkushi, Zambia. We used the National Cancer Institute (NCI) method to estimate usual intake distributions and prevalence of inadequate VA intake under five scenarios: no sugar fortification; fortification at 3.1 mg/kg or 8.8 mg/kg (median levels measured previously in Mkushi); 10 mg/kg (minimum legal requirement at household level); and 15 mg/kg (minimum legal requirement at factory level). We applied the NCI’s bivariate model to examine associations of usual intake of sugar and dietary VA with plasma and breast milk retinol concentrations measured by high performance liquid chromatography. Results Without fortified sugar, the prevalence of VA inadequacy was 83.4 % (SE: 6). Sugar fortification at 3.1 mg/kg, 8.8 mg/kg, 10 mg/kg and 15 mg/kg reduced the prevalence of VA inadequacy by 7.0 (SE:6), 23.7 (SE:14), 30 (SE:15) and 47 (SE:18) percentage points, respectively. Usual sugar intake was not associated with plasma retinol or breast milk retinol concentrations (p > 0.05). Conclusions Sugar fortification has the potential to reduce dietary VA inadequacy. However, the impact on VA intakes and any improvements in VA status are likely to be limited if the program is not implemented as planned. Even if target fortification levels are achieved (10 mg/kg), sugar fortification alone is unlikely to eliminate dietary VA inadequacy among lactating women in Zambia.