Examining the effectiveness and acceptability of the use of bio-fortified crops in alleviating micronutrient deficiencies in Pakistan

According to the World Health Organisation, dietary zinc deficiency is a global problem affecting 17% of the world's population, with the greatest burden in developing countries. The most recent national survey in Pakistan indicates that over 40% of women are zinc deficient, compared with less than 15% in Europe and North America. The consequences of zinc deficiency are profound and far reaching, ranging from stunted growth and development in children, increased susceptibility to infections in children and adults, and complications during pregnancy and childbirth. This has a negative economic impact on the family, the community and the region.
Various strategies to overcome zinc deficiency have been attempted but it is difficult to achieve when large populations are concerned. Dietary zinc supplements are expensive and do not always reach the most vulnerable groups who may live in remote or difficult to reach locations due to poor infrastructure or security problems. In contrast, biofortification of staple foods has potential as a sustainable means of increasing population dietary zinc intake. However to date, few studies have been undertaken to evaluate the efficacy and cultural acceptability of this strategy. One of the key challenges in measuring the effectiveness of such strategies is the lack of a sensitive biomarker of zinc status that is suitable for use in remote settings
We have an opportunity to evaluate the potential of a newly developed strain of biofortified wheat, produced by HarvestPlus, as a means of increasing dietary zinc intake in Pakistan. Through a collaboration with a Pakistan based fertilizer company, we will examine the impact of fertilization strategies and soil conditions on the wheat zinc content by of the addition of zinc rich fertilizer to the soil and foliage during the growing season in regions of Pakistan with contrasting soil zinc status. Previous studies have indicated that this new strain of wheat has potential to reach a zinc content that is around 45% higher than the standard varieties. The grain grown in our study will be analysed to measure the zinc content, and also the location of the zinc within the individual grains.
A double blind trial will be conducted to examine whether or not consuming the flour made from the high zinc grain has a beneficial impact on the zinc status of zinc deficient women living in a rural community in North West Pakistan. The high zinc grain will be compared with standard grain, both of which will be provided to forty families to consume for eight weeks, with group A (20 families) consuming the high zinc grain, and group B (20 families) consuming the control grain. The families will switch over after eight weeks. To monitor the impact of consuming the flour on zinc status we will use established methods (plasma and hair zinc concentration), and we will also evaluate new indicators of zinc status that have potential for use in population based surveys, including markers of DNA damage and a novel portable laser technique for measuring nail Zn concentration.
The success of a biofortification strategy requires that the intervention achieves wide and sustained uptake at production and consumption stages. Therefore, through our extensive and established networks with community leaders and farmers, we will assess the cultural context, traditions, knowledge and attitudes to biofortification in this setting, through focus groups and interviews.
A key component of this research is training and capacity building. This is a two-way process by which expertise is shared among the project partners, so that young researchers in Pakistan and in the UK are better equipped to take this important research agenda forward into the future, and to build on the collaborative links generated during this project. The findings of this research will be disseminated to researchers and policy makers word wide.

Dietary Zinc deficiency affects 17% of the world's population. In Pakistan, over 40% of women are zinc deficient (compared with less than 15% in Europe and North America). The health consequences of zinc deficiency are profound and long lasting, including stunted growth and impaired cognitive development in children, poor immune function in adults, ultimately limiting socioeconomic development. In order to address the Strategic Development Goals, it is imperative that a sustainable solution to zinc deficiency is found. Attempts to alleviate this problem include supplementation and food fortification, however both are inhibited by significant problems with compliance and efficacy. Another alternative is biofortification of staple crops which are widely consumed including by those with low purchasing power or social status.
Recently, HarvestPlus scientists in Pakistan have been able to generate a "high Zn" variety of wheat using traditional breeding techniques that is adapted to Pakistan conditions. The variety (zincol/NARC421) contains up to 40 ug/g of Zn in the grain compared to traditional varieties that contain 23 ug/g of Zn in grains, on an average. This may be enhanced by the use of fertilizers. We propose to examine the potential of consuming this grain on improving zinc status in a resource poor community in northwest Pakistan. Using a double blind cross over design, grain will be provided to a total of 40 families (20 in each arm of the study). Control or biofortified grain will be made into flour, and consumed for a period of 16 weeks, with a crossover at 8 weeks. The impact on zinc status will be assessed using established (plasma and hair zinc concentration) and novel techniques (DNA fragmentation, nail zinc by laser ablation). The cultural acceptability of biofortification in Pakistan will be explored through dialogue with consumers, community leaders and farmers.

Our goal is to reduce the prevalence of zinc deficiency in Pakistan (PK), by delivering evidence on (1) the reliability of new biomarkers of individual zinc status, (2) the effectiveness of a new variety of biofortified wheat to increase individual zinc status, (3) the cultural context, knowledge and attitudes to biofortification via crop breeding and/or fertilisers.

Communities in Pakistan where zinc deficiency is prevalent will benefit from this research. The project will provide data that will contribute to the evidence base for the potential impact of biofortification of a staple crop to alleviate zinc deficiency among the poorest communities. An integral part of this research is the dialogue with community members, leaders and farmers regarding their views about biofortification. The outcomes of this study will be disseminated to communities via the cultural appropriate mechanisms; Jirga members, elders, religious leaders as appropriate, and their reaction to the findings will be valued as part of the iterative process of taking this research beyond the life of this foundation project.

Academic researchers in the fields of Nutrition, Agriculture, Public Health, clinical biochemistry will benefit from this research. Data generated during this project will add to the body of literature relating to biomarkers of zinc status. Data relating to the role of fertilizer application on enhancing mineral uptake of staple crops will be of value to plant and soil scientists.

Policy makers and Non-profit organisations engaged in finding sustainable solutions to micronutrient deficiencies will benefit from the data and knowledge generate during this research.

Researchers within the team delivering this project will benefit from this research through the training and capacity building components that are embedded into the study design. Knowledge exchange between young and experienced researchers from the PK and UK teams will be encouraged and facilitated to build capacity to take this research agenda forwards beyond the life of this project.
Industrial Partners will benefit from this project through the opportunity to test their products under field conditions and generate data to assist with product development.

The inter-sectoral and cross- cutting nature of this research means that the results will be relevant and made accessible to a very broad scientific community. The team has a diverse membership of professional bodies and networks, at national and international level, therefore effective knowledge exchange can be achieved across a wide range of subject disciplines.