Micronutrients must have Bioefficacy

In their SciDev.Net article, Thorne-Lyman and Fawzi highlight the links between malnutrition and infectious disease. I agree with their assessment that micronutrient interventions offer a low-cost, yet underfunded, strategy for preventing and treating infectious disease, and that it is ‘time to turn knowledge into action’.

The underlying problem is that people have moved away from their traditional diets, while a combination of environmental degradation, modern agricultural practices and food processing removes essential nutrients from our food. The malnourished are being fed refined foods, fortified with vitamins and minerals in the form of chemical isolates.

In southern Africa, a traditional nutrient-rich diet would include home-grown millet and sorghum, hand-gathered herbs, roots and fruits, as well as groundnuts, sweet potato, pumpkin, cabbage and a moderate intake of free range meat, eggs and milk. The staples today are refined maize meal, bread (mostly refined) and white sugar – all of which provide ’empty calories’ – together with cooking oil and traditional margarine packed with extremely unhealthy trans-fats.

The consequences for nutrition are severe. In Mozambique, 95 per cent of children under five suffer from iron deficiency. A National Food Consumption Survey in 1999 found that South African children were deficient in iron, zinc, vitamin A and most of the B vitamins. Is it any wonder that immunity is impaired and there is an escalating prevalence of infectious disease?

To address micronutrient deficiencies, especially in the most vulnerable, South Africa began a food fortification programme in 2004, adding iron, zinc, vitamin A, B vitamins and folic acid to all maize and wheat flour. But, five years on, the project was judged a resounding failure. Apart from a modest improvement in folic acid status, the prevalence of vitamin A, zinc and iron deficiencies in children had all increased.

Hurrell evaluated wheat flour iron fortification programs in 78 countries, and concluded that most are likely to be ineffective. He argues that legislation needs updating in many countries so that flour is fortified with adequate levels of the recommended iron compounds. This ignores that fact that most legislation in this area has been framed on the advice of international agencies, and in their latest advice, the WHO states, ‘The selection of the type and quantity of vitamins and minerals to add to flour, either as a voluntary standard or a mandatory requirement, lies with national decision makers in each country and therefore the choice of compounds – as well as quantities – should be viewed in the context of each country’s situation’. This is not helpful.

Part of the problem in South Africa is that fortification is based on adult food portions. Children, who are more vulnerable, eat less and so need more highly fortified food. Another problem is that cooking can destroy the vitamins. But, most importantly, it is because chemical isolates have a significantly lower bioefficacy than whole foods. Fortifying or supplementing a defective diet with micronutrients in the form of chemical isolates is now commonplace, despite a plethora of scientific evidence that they are poorly absorbed, rarely act in the body in the way intended and, in some cases, may even be toxic.

Take, for example, the essential mineral and antioxidant, selenium. Where there is deficiency, bread or salt is often fortified with sodium selenate or selenite. But this is unlikely to have the desired benefit because these salts are toxic and poorly absorbed – and the little that is absorbed does not act as an antioxidant. It is a mad world that bans mineral water contaminated with sodium selenite – an industrial pollutant – and then puts it in bread!

The key to success in micronutrient fortification or supplementation lies in the form of micronutrient used. For the past 18 months, Health Empowerment Through Nutrition (HETN) has been working with the South African National Tuberculosis Association to provide tuberculosis patients and their families with an inexpensive and effective daily nutritional supplement. The supplement – e’Pap – costs just 18 South African Rand (US$2.38) per person per month. It is wholegrain (maize and soya), pre-cooked, and contains the recommended daily allowance of 28 important micronutrients, in a form that enhances bioefficacy, all in a small meal portion.

Recipients’ general health and wellbeing have improved dramatically. Tuberculosis cure rates have risen by 39 per cent. Now HETN is embarking on a longitudinal study with the University of the Witwatersrand to confirm these anecdotal findings and evaluate other non-invasive indicators of nutritional status.

It is now widely accepted that the Millennium Development Goals have failed to achieve the initiation of sufficient numbers of HIV positive people on anti-retroviral medications. Africa continues to experience a rampant HIV epidemic with its associated negative social and economic impact. Antiretroviral medications should remain the major focus of treatment initiatives, but a growing body of evidence of the adjunctive role of good nutrition is being ignored.

Micronutrient supplements can and do make a real contribution to alleviating the burden of infectious disease but only if they are formulated to ensure bioefficacy. Despite this, I am not aware of any global effort to reach a consensus on appropriate micronutrient supplementation in the adjunctive management of chronic health problems.

Sadly, confusion and vested interest reign.

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Dearth of Nutrition at AIDS Impact Conference

AIDSimpact logoI recently attended the AIDS Impact Conference in Gaborone, Botswana, where HETN was presenting a poster.

Very few presenters even mentioned the subject of nutrition. When we raised it, there was interest, but the consensus seemed to be:

  • (From the scientists) – Yes, nutrition is important, but it is complex, so we would rather concentrate on things we can understand.
  • (From the agencies) – Yes, nutrition is important, but it is complex and we cannot get into ‘feeding the world’.

One of the plenary speakers, Dr Gita Ramjee of the Medical Research Council, gave an excellent presentation on all possible biomedical interventions, with their strengths and weaknesses. She questioned whether the randomised control trial was always an appropriate assessment tool, but she never mentioned the role of micronutrients.

No one I spoke to had even heard of the importance of selenium.

In 1979, Chinese scientists reported that selenium had been linked to Keshan disease, an endemic juvenile cardiomyopathy (disease of heart muscle) found in the Keshan district of China. This often fatal disease has since has been found elsewhere (including New Zealand and Finland) where soil selenium levels are low.

However, certain epidemiological features of the disease could not be explained solely on the basis of inadequate selenium. Fluctuations in the seasonal incidence suggested the involvement of an infectious agent.

Indeed, a coxsackie virus isolated from a Keshan disease victim caused more heart muscle damage when inoculated into selenium-deficient mice than when given to selenium-replete mice. Vitamin E status had a similar effect on viral virulence.
Keshan disease seems to be the result of several interacting factors, including a dominant nutritional deficiency (selenium), other nutritional deficiencies (vitamin E and polyunsaturated fatty acids) and an infectious agent (virus).

Turning to HIV infection, the estimated adult prevalence rate (2007) in Bolivia was 0.2. In Senegal it was 1.0. These two countries have the highest naturally occurring soil selenium levels in the world. Comparable figures for South Africa and Swaziland, where soil selenium levels are very low, were 18.1 and 26.1 respectively. Finland had low soil selenium levels, but has been adding selenium to fertilisers since 1984. There, the estimated adult HIV prevalence rate (2007) was 0.1, whereas in neighbouring Russia and Estonia it was 1.1 and 1.3 respectively.

Kupka studied the relationship between death from AIDS and plasma selenium levels in pregnant women in Tanzania. Blood was collected from 949 pregnant women and saved for 5.7 years, by which time 306 of them had died. Statistical analysis showed that the lower the original plasma selenium level, the more likely the woman was to die of AIDS. The relationship was statistically significant.

Has selenium been shown to benefit AIDS patients? Yes. Randomised controlled trials in Nigeria (Odonukwe) and in the US (Hurwitz) have shown significant benefit.

Both these studies used selenium rich yeast. Many selenium studies show little benefit, but I have talked elsewhere about the importance of form. Where there is deficiency, it has become commonplace to fortify bread or salt with sodium selenate or selenite. This is unlikely to have the desired benefit because these salts are toxic, poorly absorbed, and the little that is absorbed does not act as an antioxidant. It is a mad world that bans mineral water that is contaminated with sodium selenite – an industrial pollutant – and then puts it in the bread! Selenomethionine is better absorbed and has some antioxidant properties. In contrast, selenium rich yeast is non-toxic, well absorbed and has powerful antioxidant properties. One would expect this, as yeast is a natural food and the selenium in it is complexed with natural carrier proteins.

In my naivety, I thought that the scientific method was about noticing something, developing a hypothesis and testing it. There is certainly much to notice about HIV prevalence and selenium status.

Sadly, there seems little interest. This is indeed strange. AIDS is about immune deficiency. The commonest cause of immune deficiency is micronutrient deficiency. Surely any AIDS intervention should start with ensuring that populations are micronutrient replete?

HETN’s poster was about TB, which kills more adults than any other infectious disease, and is often found with HIV. Ensuring that patients are micronutrient replete improves TB cure rates by 39% and only costs £1.50 per month. So cost is not the issue – but perhaps it explains the lack of interest?

Geoff Douglas

CEO – Health Empowerment Through Nutrition


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More of the Same!

I have been looking at the recent plethora of authoritative reports on Nutritional Support for People Living with HIV/AIDS (PLWHA) or TB or Famine. They come from the International Agencies. They are all lengthy. They are full of scientific citations._1502518_safrica150

 They all agree that malnutrition is widespread throughout the world, with devastating impact on the global economy.

They all support the notion of a balanced diet, but fail to mention that:

  • People in Africa have limited access to a balanced diet
  • Most people make poor food choices
  • Farming methods have depleted the soil and the food of essential micronutrients
  • Food processing, such as grain milling, removes essential micronutrients.

They usually support the use of multivitamins, but quickly add that systematic reviews of micronutrient supplementation conclude that there is no convincing evidence that these reduce morbidity or mortality in people living with HIV/AIDS. What they fail to mention is that:

  • The trials that have been done concentrate on single supplement intervention, or supplementation with a small group of micronutrients. Neither can be expected to correct the type of nutrient deficiency seen in HIV/AIDS
  • The problem is compounded by the fact that the dose of supplement is often not physiological and the form of supplement is often not considered
  • Much of the research is done in the West where baseline nutrition is higher.

The truth is that:

  • People have moved away from their traditional foods, whilst modern agricultural practices and food processing remove essential nutrients from the food chain
  • Many communities are experiencing health problems not seen by their grandparents who often lived in greater poverty
  • Science has had limited success in providing solutions to this problem and there is confusion as to what represents good nutrition.
  • On the advice of GAIN and the Micronutrient Initiative, the malnourished are being fed refined foods, with added vitamins and minerals in the form of chemical isolates – despite evidence of their limited bio-availability.
    • In South Africa, iron, zinc and vitamin A deficiency is widespread. Their maize and wheat flour fortification programme has not addressed these deficiencies. This is not surprising:
    • The electrolytic iron used has a bio-availability of less than 2%
    • Phytates in maize further reduce this
    • The electrolytic zinc used competes with the iron for absorption
    • Electrolytic iron oxidizes the vitamin A
    • The added vitamins are denatured and destroyed by cooking.

In order to have any chance of health, human beings need whole foods with bio-available vitamins and minerals. Where access to fruit and vegetables is limited, wholegrain cereals need to be fortified with vitamins and minerals in a bio-available form. Neither of these terms is ever used in these authoritative reports.

 The scientific community has paid little attention to the crucial issue of nutrient form. Most scientific papers do not mention it. Some examples:

  • Iron. Chelated Iron is better absorbed and less toxic than ferrous sulphate.
  • Calcium. Research has shown that 30mg of Calcium rich yeast is better absorbed than 300mg of Calcium Carbonate.
  • Selenium. Selenium is an essential trace element – required for an extensive range of biochemical functions – mediated by some 20 selenoproteins that play a key role in antioxidant systems, thyroid hormone metabolism, immune function and reproduction.
    • Where there is deficiency, it has become commonplace to fortify bread or salt with sodium selenate or selenite. But this is unlikely to have the desired benefit because these salts are toxic, poorly absorbed, and the little that is absorbed does not act as an antioxidant. South Africa bans the sale of mineral water if it is contaminated with sodium selenite – an industrial pollutant – but permits its use in bread!
    • Selenomethionine is better absorbed and has some antioxidant properties, whereas selenium rich yeast is non-toxic, well absorbed and has powerful antioxidant properties. One would expect this as yeast is a natural food and the selenium in it is complexed with natural carrier proteins.
  • Vitamin C. We need our vitamins and minerals as food or in a food form. When the discoverer of Vitamin C, Szent-Györgyi, tried his crystalline ascorbic acid on patients with scurvy, he expected a strong reaction – but it did nothing. The concentrated whole foods he used in his research were far more effective. He attributed this to complex food factors, such as bioflavonoids, present in the food.

Oh dear, oh dear!


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A Lifeline for TB Patients – Cure Rates Improve by 39%

Of all infectious diseases, TB is the leading killer of adults in the world today.TB

  • It kills approximately 2 million people each year.
  • It is estimated that, between 2002 and 2020, over 150 million people will become ill, and 36 million will die if there is not better control.
  • In Africa, TB is escalating out of control and drug resistance is now common.

And yet:

  • The association between TB and malnutrition has long been known.
  • Malnutrition weakens immunity, increasing the chance that latent TB will develop into active disease.
  • TB makes malnutrition worse.

At the 2008 Annual Conference of the South Africa National Tuberculosis Association (SANTA), Dr Geoff Douglas, CEO of Health Empowerment Through Nutrition (HETN) challenged those attending:

  • Antibiotics are essential elements in curing TB.
  • But without the basics of good nutrition to sustain or rebuild natural health and immunity, we are fighting a losing battle.
  • If it is the consensus that the maintenance of health is conditional on eating a balanced diet, this should be the first priority in any health initiative.
  • It is the responsibility of all health workers to ensure that their patients are nutrient replete.
  • Advising patients to eat a balanced diet, where they have no access or no understanding, is unethical.

It was agreed that HETN would fund a SANTA programme to bring e’Pap to TB patients, their families and care workers.


  • e’Pap is a pre-cooked, wholegrain food, based on maize and fortified with soya and a cocktail of 28 nutrients.
  • e’Pap is produced in Africa where its composition and brand name are suited to Africa’s taste and tradition.
  • The formulation is based on a local understanding of nutritional need, and uses state of the art, first world fortification chemistry to ensure bio-availability and bio-efficacy.

There was some initial scepticism.

  • When e’Pap was introduced, no one believed that it would save lives. But we have seen miracles.
  • When everyone was losing hope, this miracle pap came to save lives. We used to cry and wonder why people should be so sick. Today, we walk with a smile and songs in our hearts, because we have witnessed the dead brought back to life.
  • With this little sachet we can heal the nation; we can change the world.

Such anecdotal evidence, however dramatic, rarely persuades the scientists, but read on.

Seun Maphoroma, the SANTA Co-ordinator for Gauteng Province, reports that, on the 20/03/2009, he attended an event at the Odi stadium, north east of Pretoria, to mark World TB Day. During his address, Brian Hlongwa, MEC for Health, reported that the cure rate for TB in Tshwane Odi area had improved from 56% to 78% – a 39% increase. He dearly wanted to know the reason. Agnes Mphangane, one of the Odi SANTA branch members in attendance, jumped to her feet to explain that this dramatic change had occurred since SANTA began distributing e’Pap to TB patients and their families.

e’Pap changes lives.

If 39% improvement was the response to a new drug, the world would be jumping up and down, but as Ayn Rand said: ‘The hardest thing to explain is the glaringly evident which everybody had decided not to see.’

John Heinrich, SANTA CEO, writes:

  • On behalf of SANTA, I would like to express our appreciation of the partnership enjoyed with HETN in the distribution of e’Pap to TB patients, their families and care workers.
  • The pilot project of 2 tons of e’Pap per month is proving highly successful. The greatest impact is being seen on very ill / bedridden patients.
  • Reports from recipients indicate that e’Pap is far more beneficial than supposed enriched foods received before.
  • These e’Pap projects have proved most valuable and are well received.
  • Their continuation and expansion is seen as one of the three major objectives of SANTA in the continuing fight against TB and HIV/AIDS – namely Nutrition, Awareness and Directly Observed Therapy (DOTS).
  • SANTA is in no doubt that improved nutrition can revolutionise the fight against both TB and HIV/AIDS.

You can help this work. Please donate through – http://www.justgiving.com/hetn/donate


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HETN has Grave Concerns about Plumpy’nut for Long Term Use

Plumpy'nutPlumpy’nut is promoted and marketed across Africa as a major breakthrough in the fight against malnutrition.

Based on peanut butter, milk powder and sugar, it was designed to be used for a maximum of 2 to 3 weeks in cases of severe acute malnutrition. This may be appropriate, but is not the reality on the ground, and therein lies the problem.

For ongoing supplementary feeding, it is HETN’s contention that:

  • The high level of protein in Plumpy’nut is not appropriate.
  • The milk powder base can cause diarrhoea in the many who have lactase deficiency.
  • The high levels of oil and refined sugar (30%) are inappropriate and would make such a product unacceptable for children in the UK.
  • The high cost of the components makes it unaffordable, and therefore unsustainable in the African context, without donor funding.

Plumpy’nut uses a micronutrient cocktail of chemical isolates. These are not effectively absorbed, and have little impact in addressing the nutritional needs of the malnourished. For example:

  • The recommended daily intake of Plumpy’nut contains 13mg of inorganic iron with a bio-availability of about 0.26mg (2%).
  • Where inorganic iron is combined with inorganic zinc, some 60% of the iron is blocked. This further reduces the absorbed iron to about 0.1mg.
  • A healthy child requires 1mg per day of absorbed iron and, if malnourished or sick, could need 2mg.
  • So, how could Plumpy’nut ever address iron deficiency in a child when it delivers less than 10% of a child’s daily needs?

People everywhere, malnourished or not, need a diet that is based on whole grains.

  • It should be low in fat and sugar.
  • It should contain all the vitamins and minerals that would ideally be sourced from fruit and vegetables in a form that is bio-available.

e'PapSuch a product – e’Pap – has been available in Africa for years, and has been used successfully with malnourished people.

HETN supports e’Pap – a pre-cooked, wholegrain food, based on maize and fortified with soya and a cocktail of 28 nutrients. e’Pap is produced in Africa where it’s composition and brand name are suited to Africa’s taste and tradition. The formulation is based on a local understanding of nutritional need, and uses state of the art, first world fortification chemistry to ensure bio-availability and bio-efficacy.

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Hidden Hunger – Part 5

Ration Books







UK Wartime Rationing (1940-1954) prescribed:

Very little meat, fat, eggs or sugar

  • 2 ounces (50g) of butter per week
  • One egg per fortnight

The ‘National Loaf’ – wholegrain
Home-grown vegetables – ‘Dig For Victory’
An apple a day keeps the doctor away

  • Children were allocated milk, cod-liver oil and orange juice
  • Schoolchildren had a weekly dose of malt extract.

Presumably, a stressed population – with limited food choices – suffered nutritionally? Not so. Most people were better fed during wartime food rationing than before the war years

  • Infant mortality rates declined
  • The average age at which people died from natural causes increased.

People everywhere, malnourished or not, need a diet that is based on whole grains. It should be low in fat and sugar. It should contain all the vitamins and minerals that would ideally be sourced from fruit and vegetables in a form that is bio-available.

In the UK in 1940 they could not wait for the science.

  • They were at war
  • They had to act on the RDA (Recommended Daily Allowance) information that was available
  • In the process, they improved the health of all.

Today there is no time to waste.

  • We are at war
  • In Africa, the front line is dying of TB, Malaria, AIDS and Diabetes, while we sit in ivory towers arguing science.

It makes no sense at all to grow depleted food, then remove many of the essential nutrients (refining), then try to put them back as chemical isolates!

An enlightened government would:

  • Provide education on this dietary emergency
  • Focus on achieving nutrient repleteness by appropriate supplementation and/or food fortification (bio-available micronutrients in a food form)
  • Encourage the production of fresh food locally, at household and community level, including sprouting, worm composting, permaculture, tyre gardening, etc.

It would take control of the food supply chain:

  • Ban the refining of maize, wheat & rice for 3-5 years and invest in the capacity to store this food
  • In Africa, change much of the maize production capacity to sorghum and other grains and introduce these as a mix into maize meal products
  • Introduce a ban on deep ploughing, and rate foods by the quality of the topsoil and nutrient content of the food, with a farmer subsidy system to promote better ratings.

The time is now.

Dr Geoff Douglas
CEO – Health Empowerment Through Nutrition

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Pure, White and Deadly – An Appeal for Raw Sugar

Raw SugarOver the last few years, there has been a worldwide explosion in the prevalence of Type 2 diabetes – the third leading cause of death in the US. Type 2 diabetes occurs where there is sufficient insulin, but when insulin receptors become less sensitive.

This insulin resistance is the common factor in a cluster of cardiovascular disease risk factors known as metabolic syndrome. 20% of adult Americans have it, and it affects up to 40% of those over 60.

These shocking statistics mirror the loss of chromium from our diets, owing to soil deficiency and the refining of foods. Even when chromium is present in food, processing removes up to 80% of it. Significant amounts of minerals are lost from whole wheat and raw sugar when they are processed to white flour (40% loss) and refined sugar (93% loss) – two of the main constituents of the Western diet. As a result, an estimated 25-50% of these populations are chromium deficient.

Chromium is an essential mineral, important for health, that has a beneficial role in the regulation of insulin action. Chromium controls hunger, reduces cravings, helps stabilise blood sugar and lowers cholesterol levels.

In its metallic form, chromium is indigestible. In a food form, it is indispensable. Although needed only in minute amounts, most people don’t get enough in their daily diets.

But why is chromium so important? Chromium helps metabolise carbohydrates to produce energy. The process begins when the digestive enzymes in the gut break down complex carbohydrates to simple sugars, which raise the level of blood glucose. In order for this glucose to provide energy, it must be escorted into each of the body’s cells, where the energy conversion takes place. The ‘escort’ is insulin. Insulin does not work properly unless chromium is present as a cofactor.

In a state of chromium deficiency, glucose builds up in the blood, and not enough is transported into the cells. A person in this situation is said to be glucose intolerant.

Symptoms of chromium deficiency include frequent hunger, excessive thirst, addiction to sweet foods, fatigue and irritability. Those who are stressed or who eat a diet high in refined sugars and flours are at risk. Refined foods are very low in chromium, and sugar increases chromium loss. Milk and other high-phosphorus foods, such as refined maize, bind with chromium in the gut to make chromium phosphate that is not absorbed.

Indians in KwaZulu-Natal, South Africa, consume nine times the amount of sugar that Indians consume in India, and they have suffered a veritable explosion of diabetes ‑ believed to be the highest in the world.

It is clear that public health programmes should move from the detection and treatment of diabetes to preventive nutrition ‑ principally, replacing refined foods with whole foods.

Excellent natural sources of chromium are yeast, whole grain flours and potatoes. But raw sugar is also rich in chromium. So Nature provides its sweetener with the cofactor that facilitates its handling and reduces craving. Raw sugar is also rich in calcium, cobalt, copper, iron, manganese, magnesium, selenium and zinc. All these essential trace minerals are removed in the refining process, and a similar document could be written on the importance of each of them.


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