A Study on Awareness and Consumption of Fortified Foods among Female Adults of Mumbai

Introduction: Food fortification is likely to have played an important role in current nutritional health and well-being of populations in industrialized countries. Malnutrition is one of the biggest development challenges facing the world. Over 2 billion people lack the essential vitamins and nutrients needed to grow and live healthy lives. Aim: To assess the awareness, attitude and consumption of females towards food fortification in Mumbai. Method: A study was conducted on 100 females between the age group of 18 to 60 years using a structured questionnaire. A statistical package of social sciences (SPSS) version 16 was used for analysis. Results: Over 43subjects were aware about the definition of food fortification (χ2 = 75.48, p <0.01) & 52subjects knew that salt should be compulsorily fortified with iodine in India (χ2 = 133.80, p <0.01).Over 76subjects consumed fortified foods (χ2 = 85.76, p <0.01)& while28 consumed because it’s healthy, other 28gave a mixed response (χ2 = 54.75, p <0.01). Only 64subjects responded that it’s affordable (χ2 = 13.17, p <0.01) and42subjects got aware about it by reading on the pack of the container or through TV/magazines/newspaper/internet (χ2 = 66.16, p <0.01). Breakfast cereals were consumed once in a while on a monthly basis; Breads and biscuits on a weekly basis; Snack bars on monthly basis; AmulTaaza Milk, Gemini Refined Sunflower Oil and Tata salt plus were on a daily basis and all Beverages were of mixed combinations. Conclusion: The overall awareness regarding food fortification was poor. Although the attitude was not purposeful towards fortified foods, the consumption was unconsciously more due to the availability of such products in the market.


Introduction
Fortification of foods with micronutrients is a technologically, programmatically and economicallyeffective method of increasing micronutrient intakes in populations.Food fortification is likely to have played an important role in current nutritional health and well-being of populations in industrialized countries [1].One of the consequences of industrialization is reduced intake of many micronutrients, because of the large dependence of the food industry on salt, sugar, vegetable fats and refined cereals, all of which are poor sources of vitamins and minerals [2].Malnutrition is one of the biggest development challenges facing the world. Over 2 billion people lack the essential vitaminsand nutrients needed to grow and live healthy lives [3].A fortified food can be defined as an edible product (staple food, processed food, condiment, or product for special groups) manufactured by the food industry with a nutritional composition that is enhanced by the addition of vitamins and minerals [4]. Codex Alimentarius Principles for the Addition of Essential Nutrients to Foods (General Principles for the Addition of Essential Nutrients to Foods, 1991) defines "fortification", or synonymously "enrichment", as "the addition of one or more essential nutrients to a food, whether or not it is normally contained in the food, for the purpose of preventing or correcting a demonstrated deficiency of one or more nutrients in the population or specific population groups" [5].Fortification can be classified as either mandatory or voluntary. Mandatory fortification occurs "when governments legally oblige food producers to fortify particular foods or categories of food with specified micronutrients."Voluntary fortification is when a "food manufacturer freely chooses to fortify particular foods in response to permission given in food law, or under special circumstances, is encouraged by government to do so" [6]. Main Types of Food Fortification programs are Mass fortification; The addition of micronutrients to foods commonly consumed by the general public, Targeted fortification; The addition of micronutrients to foods designed for specific population subgroups, Marketdriven fortification; The situation where the food manufacturer voluntarily takes the initiative to add one or more micronutrients to processed foods, usually within regulatory limits, in order to increase sales and profitability, Bio fortification; The breeding and genetic medication of plants to improve their nutrient content and/or absorption of foods which are engineered to have greater nutrients [7]. Being a food-based approach, food fortification offers a number of advantages over other interventions aimed at preventing and controlling Micronutrient Malnutrition (MNM); maintaining body stores of nutrients, lowering the risk of the multiple deficiencies, supplies micronutrients in amounts that approximate to those provided by a good, wellbalanced diet, has the potential to improve the nutritional status of a large proportion of the population, feasible to fortify foods with several micronutrients simultaneously and cost effective [6].

Methodology
A detailed knowledge, aptitude and practise study was conducted in Mumbai on 100 females between the age group of 18 to 60 years irrespective of their caste, occupation and educational background belonging to random areas of Mumbai depending on the researcher's contacts and proximity like South Mumbai, Santa Cruz West and Vile Parle. Females from nutrition or dietetics field and Males were excluded. Purposive sampling technique was used to  who actively and willingly  participated which used to collect information regarding  whether they find fortified food products healthy, knowledge  regarding the term "fortification", practice regarding use of  fortified foods and which specific food products they  consume with the help of a food frequency table. Subjects were explained about any query regarding the questions stated in the questionnaire and then asked to fill the detailed questionnaire. A statistical package of social sciences (SPSS) version 16 was used for analysis.

Basic Characteristics of Study Participants:
In total, 100 Females were recruited in the current study. Age of participants ranged from 18 to 60 years with a mean of 29.52 ± 11.72. 69 (69.00%) were Muslims; 79 (79.00%) were Non-Vegetarians. Qualification of participants ranged from below high school to post graduates, where 35 (35.00%) were graduates; 41 (41.00%) subjects were students and 56 (56.00%) subjects belonged to middle socio -economic class (MSEC).

Awareness Of Food Fortification:
The objectives of the current research were to investigate a range of issues around public awareness. Specific information about consumers' awareness and understanding of fortification was sought.

Table 1describes
the awareness and knowledge of females in Mumbai regarding food fortification. Six questions were asked to assess the knowledge. *p value < 0.05 was considered to be significant **p value < 0.01 was considered to be highly significant When study participants were asked about the definition of food fortification,43 (43.00%) responded addition or enrichment of food product. These differences were highly significant (χ 2 = 75.48, p <0.01). Majority of the participants were aware about the definition of food fortification.
When subjects were questioned on which part of the food product are fortification details mentioned, 27 (27.00%) responded nutrition information panel. These differences were highly significant (χ2 = 44.16, p <0.01). Highest per cent of participants were of the opinion that any fortification detail will be in the nutrition information panel.
Out of 100females, 44 (44.00%) subjects responded that government makes it compulsory for the manufacturer to fortify some food products. These differences were significant (χ2 = 7.28, p <0.05). Though most of the subjects were aware about compulsory fortification, some were unsure.
When female subjects were asked about their knowledge regarding which food products are fortified in India,54 (54.00%) gave a mixed response. These differences were highly significant (χ2 = 2.38, p <0.01). Majorly subjects were of the mixed response that breakfast cereals, biscuits and salt are fortified with vitamins/minerals in India. Twenty days intake of Se-enriched-rice increase the serum selenium levels and erythrocyte glutathione peroxidase (GPx) activity [8].
Which vitamins/ minerals are used in the fortification of foods; 33 (33.00%) gavemixed response and 33 (33.00%) were not sure. These differences were highly significant (χ2 = 1.62, p <0.01). Most subjects gave a mixed response of Vitamin D, Calcium, Iron& Iodine while others were unsure. Consumption of an Fe-fortified breakfast cereal with kiwifruit compared with banana improved Fe status [9].
When inquired about the mineral with whichsalt should be fortified,52 (52.00%) said Iodine. These differences were highly significant (χ2 = 133.80, p <0.01). More than half of the participants knew that salt should be compulsorily added with iodine while few gave a mixed response with Iodine and Iron. Double fortified salt (DFS) is an efficacious approach to improving iron status [10]. Multiple micronutrient fortified salt was able to improve iron and vitamin A status [11].

Attitude of Females Towards Food Fortification
After assessing the knowledge of the participants, the study focused on various aspects of attitude and behavior of subjects towards fortified foods. Table 2 describes the attitude of females regarding food fortification. Thirteen questions were asked to assess the basic attitude of participants towards fortified food products. When asked specifically to the participants those who consumed fortified foods about the food items, 50 (65.8%) subjects gave a mixed response. These differences were highly significant (χ2 = 2.15, p <0.01). Majority of the subjects gave a mixed combination of breakfast cereals, biscuits, salt, milk & milk products.
When subjects were inquired for the reasons of not purchasing fortified foods,1 (25.00%) reported respectively for each thatthey are unaware, it's expensive, not beneficial, and not available in the area they live. These differences were non-significant (χ2 = 0.85, p >0.05).
When asked about the reasons for consuming fortified foods, 28 (30.10%) reported because it's healthy while other 28(30.10%) said it's healthy as well as increases strength and improves immunity. These differences were highly significant (χ2 = 54.75, p <0.01). In general, most of the participants consumed fortified food because it's healthy.
Forty (43.00%) subjectsreported their health condition improved after consuming fortified food products. These differences were significant (χ2 = 7.54, p <0.05). Highest percent of subjects had improved health after consumption of fortified foods.
Sixty four (68.80%)subjects reported that fortified foods are affordable. These differences were highly significant (χ2 = 13.17, p <0.01).Fortification with iron, iodine, and potentially zinc provides significant economic benefits and the low unit cost of food fortification ensures large benefit: cost ratios, with effects via cognition being very important for iron and iodine [12].
Forty-two (45.20%) subjects gained awareness about fortification by reading on the pack of the container. These differences were highly significant (χ2 = 66.16, p <0.01).
Majorly subjects got aware about fortification by reading on the pack of the container or TV/magazines/newspaper/internet. When asked about conscious purchasing of food items, 51 (54.80%) subjects read the food label before buying fortified food. These differences were non-significant (χ2 = 0.87, p >0.05). About half of the subjects do conscious purchasing of fortified foods.
Overall Acceptability: Thirty six (38.70%) subjects reported that the overall acceptability of the fortified food product made no difference in their consumption, while 31 (33.30%) felt it did affect their consumption and 26(28.00%) were sure that it did not affect their consumption. These differences were non- significant (χ2 = 1.61, p >0.05).
Majority of the subjects agreed that fortification has changed the taste, texture and appearance of the food products. However the overall acceptability of the fortified food products made no difference in their consumption.

Consumption Of Fortified Foods:
A list of total 102 fortified food products was prepared and attached to the food frequency questionnaire (FFQ) and the options provided in the FFQ were daily, weekly, fortnightly and monthly. Data was collected on frequency of consumption of total 102 products.
Each graph describes the frequency (percentage) of individuals consuming the fortified foods. The participants were asked to describe the frequency of consumption of fortified food items within each food group. The maximum frequency is highlighted. From the data collected, Figure 1 shows that out of total 29 products of breakfast cereals, highest frequency was reported under monthly consumption for 21 products. Four products reported highest frequency under weekly category, among them Kelloggs Honey loops (56.00%) was consumed by maximum participants followed by Kelloggs Cornflakes Brownie delight (37.50%), Original and the Best (35.10%) and Frosties(35.30%). However for 3 products the highest frequency reported were in combinations; KelloggsOatbites(28.00%) for daily and fortinightly, Kelloggshoneyloops (wholegrain)(10.00%) for weekly and monthly and Kelloggs Special K (Chocolate & Strawberry)(37.90%) for daily and monthly. Kelloggs Special K (11.00%) was the only product with the highest frequency reported under the daily category. Out of 100 female subjects, most of them consumed breakfast cereals once in a while on a monthly basis. Consumption of 1 cup fortified breakfast cereal daily significantly increased B vitamin and decreased homocysteine concentrations, including post methionine-load homocysteine concentrations [13]. The addition of a moderate amount of calcium to a cereal product was beneficial to calcium absorption and did not interfere with iron absorption. Use of calcium-fortified food products may be considered a practical approach to increasing the calcium intake of children [14].      Figure 6 shows that 3 were of the highest frequency consumed under daily category among them were Gemini Refined Sunflower Oil (76.50%) followed by SundropNutrilife Oil (40.50%) and Godrej Refined Sunflower Oil (40.00%). While only AmulLite (Bread Spread) (42.20%) and Riso -Rice Bran Oil (50.00) was each reported with highest frequency for weekly and monthly, respectively. Two products were reported with frequencies in combinations; Nutralite -Butter (33.30%) for daily and weekly while Dhara -Filtered Groundnut oil (33.30%) for daily and monthly. The highest frequency of product reported under daily basis was Gemini Refined Sunflower Oil (76.50%).

Conclusion
The overall awareness regarding food fortification and fortified food products was poor. Although the attitude was not purposeful towards fortified foods, the consumption was unconsciously more due to the availability of such products in the market.