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

Lead Research Organisation: University of Central Lancashire
Department Name: Sch of Sport and Wellbeing

Abstract

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.

Technical Summary

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.

Planned Impact

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.
 
Description Objective 1. Note: As the data analysis is still underway, the study is still blinded. Mean dietary zinc intake at baseline was 6.4 mg/day (SD 3.8) with a range of values from 1.2 to 21.9 mg/day. The diet was high in vegetables and unrefined cereal grains and was therefore classified as having a phytate content, thus a low zinc bioavailability (according to FAO criteria). According to the International Zinc Nutrition Consultative Group (iZiNCG), the recommended daily intake for zinc from unrefined, low bioavailability diets is 9.0 mg/day for adult women; 80% of study participants consumed less than 9.0 mg/day. Mean plasma zinc concentration (PZC) at baseline was 696.5 µg/L (SD 117.9) with a range of values from 435.9 to 1060.8 µg/L. For the assessment of the risk of zinc deficiency in populations, iZiNCG suggested a lower cutoff of 660 µg/L for adult women (non-pregnant, non-fasted); 30% of study participants had PZC less than 660 µg/L. Multiple biomarker analysis at each time point is still in progress.
Objective 2: Fauji Fertilizer Company (FFC) coordinated field experiments at three experimental sites across Pakistan in 2017/18. The aim was to determine the value of adding zinc fertilisers to wheat production in Pakistan, both in terms of yield and the potential health benefits from increasing the zinc concentration in the grain of the wheat used to make roti or chapatti. At each of the three experimental sites (Faisalabad, Islamabad, and Pir Sabak, representing soils of 'high', medium' and 'low' zinc status, respectively), replicated plots were sown of the high-zinc wheat variety released by HarvestPlus (Zincol-2016) and a local reference variety of wheat. Eight fertiliser treatments were used, including zinc fertilisers applied to (1) soils only (basal), (2) foliage at booting via sprays (foliar), and (3) combinations of basal and foliar applications. In control plots, which received no zinc fertilisers, the grain zinc concentration was consistent with the amount of 'plant available' (DTPA-extractable) in the soils. This indicates that the spatial effects of soils on grain quality warrants further investigation. Across all sites, there was an increase of 20-60% in grain zinc concentration when foliar zinc fertiliser was applied, however, there was no consistent effect of basal zinc fertiliser on grain zinc concentration. Zincol-2016 outperformed local varieties in terms of yield and grain zinc concentration at the 'low' and 'medium' zinc status sites. The experiment is being repeated in 2018/19 at the same sites, using a refined experimental design, using additional funds secured by UCLan and in kind support from FFC and the University of Nottingham.
Objective 3: A subsample of 10 (out of 50) households from the RCT was randomly selected. Five male heads of household and five female trial participants were interviewed. Questions related to participants' experiences of using the new flour during the trial, comparisons with their usual flour, awareness of potential health benefits, willingness to purchase biofortified (zinc-enriched) flour if it becomes available in the future, and wider community perceptions. In addition, a questionnaire survey was conducted to explore farmers' views and perspectives on biofortification. Farmers who had grown Zincol-2016 were recruited from Sindh Province. Preliminary themes emerging from the interview data suggest that participants preferred the flour provided during the RCT to their usual flour purchased from the local market. They preferred the texture of the new flour (good for kneading) and the taste of the bread (sweeter) and found it lighter on the stomach. They reported a range of perceived health benefits, which they attributed to the new flour, including improved digestion, reduced heartburn, reduced aches and pains. They said they would like to purchase biofortified flour, if the price was affordable, and would recommend it to other community members. A total of 66 farmers participated in the survey. The findings suggest they were well informed about biofortification; the higher zinc content and potential health benefits were important factors in their decision to grow Zincol. However, they did not use zinc fertilizers on the crop (reasons unknown). All participants said they received the same price for Zincol as for other local varieties of wheat, and 86% said they obtained a higher yield from Zincol. Some farmers provided feedback on growing conditions, such as preferred soil type, susceptibility to disease and fertilizer requirements. All participants said they planned to continue growing Zincol.
Objective 4. Pakistan-based researchers and technicians were successfully trained in a variety of techniques to minimise contamination, and protect the integrity of the samples. We jointly developed practical documents to operationalise the study protocol: data collection sheets, sample recording sheets, quality assurance procedures. Interview skills training was provided during our mid-project meeting in March 2018. We developed the semi-structured interview questions collaboratively. Our partners in Pakistan have contributed to international dissemination activities including the ANH Academy in Ghana in June 2018 and the Nutrition Society Conference in UK in July 2018. The whole research team participated in our research symposium at the National Agricultural Research Centre in Islamabad, Pakistan in March 2018.
Exploitation Route The findings will inform policy regarding the future release of Zincol2016 biofortified wheat in Pakistan. In addition, information about the potential usefulness of the biomarkers being evaluated will be useful for researchers investingating the inpact of dietary zinc interventions.
Sectors Agriculture, Food and Drink

URL https://www.uclan.ac.uk/research/explore/projects/bizifed-project.php
 
Description BiZiFED project partners 
Organisation Fauji Fertilizer Company
PI Contribution UCLan's contributions include research management, knowledge and expertise, data management, data analysis, capacity building.
Collaborator Contribution The project partners listed above have contributed in many ways to the ongoing success of this project, including knowledge and expertise, development and distribution of seed, development of zinc fertilizers, management of field experiments, stakeholder engagement, community engagement, participant recruitment and retention, data collection, laboratory facilities, data entry, capacity building.
Impact In March, we will travel to Pakistan for our mid-project meeting with partners listed above. We will also host a research symposium with invited delegates from the Department for International Development (DFID), the British Council, HarvestPlus, Nutrition International, Scaling Up Nutrition (SUN), the National Agriculture Research Centre and Khyber Medical University. This will be an opportunity to share preliminary findings from our study and develop relationships with potential future collaborators.
Start Year 2017
 
Description BiZiFED project partners 
Organisation Khyber Medical University
PI Contribution UCLan's contributions include research management, knowledge and expertise, data management, data analysis, capacity building.
Collaborator Contribution The project partners listed above have contributed in many ways to the ongoing success of this project, including knowledge and expertise, development and distribution of seed, development of zinc fertilizers, management of field experiments, stakeholder engagement, community engagement, participant recruitment and retention, data collection, laboratory facilities, data entry, capacity building.
Impact In March, we will travel to Pakistan for our mid-project meeting with partners listed above. We will also host a research symposium with invited delegates from the Department for International Development (DFID), the British Council, HarvestPlus, Nutrition International, Scaling Up Nutrition (SUN), the National Agriculture Research Centre and Khyber Medical University. This will be an opportunity to share preliminary findings from our study and develop relationships with potential future collaborators.
Start Year 2017
 
Description BiZiFED project partners 
Organisation London School of Hygiene and Tropical Medicine (LSHTM)
Country United Kingdom 
Sector Academic/University 
PI Contribution UCLan's contributions include research management, knowledge and expertise, data management, data analysis, capacity building.
Collaborator Contribution The project partners listed above have contributed in many ways to the ongoing success of this project, including knowledge and expertise, development and distribution of seed, development of zinc fertilizers, management of field experiments, stakeholder engagement, community engagement, participant recruitment and retention, data collection, laboratory facilities, data entry, capacity building.
Impact In March, we will travel to Pakistan for our mid-project meeting with partners listed above. We will also host a research symposium with invited delegates from the Department for International Development (DFID), the British Council, HarvestPlus, Nutrition International, Scaling Up Nutrition (SUN), the National Agriculture Research Centre and Khyber Medical University. This will be an opportunity to share preliminary findings from our study and develop relationships with potential future collaborators.
Start Year 2017
 
Description BiZiFED project partners 
Organisation The Abaseen Foundation U.K.
PI Contribution UCLan's contributions include research management, knowledge and expertise, data management, data analysis, capacity building.
Collaborator Contribution The project partners listed above have contributed in many ways to the ongoing success of this project, including knowledge and expertise, development and distribution of seed, development of zinc fertilizers, management of field experiments, stakeholder engagement, community engagement, participant recruitment and retention, data collection, laboratory facilities, data entry, capacity building.
Impact In March, we will travel to Pakistan for our mid-project meeting with partners listed above. We will also host a research symposium with invited delegates from the Department for International Development (DFID), the British Council, HarvestPlus, Nutrition International, Scaling Up Nutrition (SUN), the National Agriculture Research Centre and Khyber Medical University. This will be an opportunity to share preliminary findings from our study and develop relationships with potential future collaborators.
Start Year 2017
 
Description BiZiFED project partners 
Organisation University of Nottingham
Country United Kingdom 
Sector Academic/University 
PI Contribution UCLan's contributions include research management, knowledge and expertise, data management, data analysis, capacity building.
Collaborator Contribution The project partners listed above have contributed in many ways to the ongoing success of this project, including knowledge and expertise, development and distribution of seed, development of zinc fertilizers, management of field experiments, stakeholder engagement, community engagement, participant recruitment and retention, data collection, laboratory facilities, data entry, capacity building.
Impact In March, we will travel to Pakistan for our mid-project meeting with partners listed above. We will also host a research symposium with invited delegates from the Department for International Development (DFID), the British Council, HarvestPlus, Nutrition International, Scaling Up Nutrition (SUN), the National Agriculture Research Centre and Khyber Medical University. This will be an opportunity to share preliminary findings from our study and develop relationships with potential future collaborators.
Start Year 2017
 
Description Article in The Conversation January 2018 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Article in The Conversation January 2018 entitled: Scientists are breeding super-nutritious crops to help solve global hunger. The aim was to raise awareness about biofortification, its potential impact on micronutrient deficiencies and our research in Pakistan.
Year(s) Of Engagement Activity 2018
URL https://theconversation.com/scientists-are-breeding-super-nutritious-crops-to-help-solve-global-hung...
 
Description Article in The Independent February 2018 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Biofortification: Scientists are breeding super-nutritious crops to help solve global hunger
Year(s) Of Engagement Activity 2018
URL http://www.independent.co.uk/news/science/biofortification-crops-global-hunger-super-nutritious-scie...
 
Description Article on the Genetic Literacy Project May 2018 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Media (as a channel to the public)
Results and Impact 'Biofortification': Super-nutritious crops could help millions of undernourished children
Year(s) Of Engagement Activity 2018
URL https://geneticliteracyproject.org/2018/05/30/biofortification-super-nutritious-crops-could-help-mil...
 
Description Article on the World Economic Forum February 2018 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Scientists are breeding super-nutritious crops to help solve global hunger
Year(s) Of Engagement Activity 2018
URL https://www.weforum.org/agenda/2018/02/scientists-are-breeding-super-nutritious-crops-to-help-solve-...
 
Description BBSRC Business Summer 2018 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Industry/Business
Results and Impact Global Food Security: Tackling the hidden hunger
Year(s) Of Engagement Activity 2018
 
Description Global Food Security Blog March 2018 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Media (as a channel to the public)
Results and Impact Hidden Hunger: Biofortified wheat and zinc deficiency in Pakistan
Year(s) Of Engagement Activity 2018
URL https://www.foodsecurity.ac.uk/blog/hidden-hunger-biofortified-wheat-zinc-deficiency-pakistan/
 
Description Global Forum on Food Security and Nutrition 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other audiences
Results and Impact Participants were invited to share their views on the role played by the nexus between agriculture, food security and nutrition, and the environment towards advancing the realization of the Sustainable Development Goals.
Year(s) Of Engagement Activity 2018
URL http://www.fao.org/fsnforum/activities/discussions/sustainable-farming-systems
 
Description Presentation at ANH Academy 2018 by Heather Ohly 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact A randomised controlled trial to examine the effectiveness of biofortified wheat as a strategy to reduce zinc deficiency in Pakistan
Year(s) Of Engagement Activity 2018
 
Description Presentation at Zinc-Net Meeting 2019 by Heather Ohly 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact Biofortified Zinc Flour to Eliminate Deficiency in Pakistan (the BiZiFED project)
Year(s) Of Engagement Activity 2019
 
Description Presentation at Zinc-Net Meeting 2019 by Nicola Lowe 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact The Global challenge of Zinc Deficiency: research to find a sustainable solution in Pakistan
Year(s) Of Engagement Activity 2019
 
Description Seminar at Liverpool Hope University by Heather Ohly 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Postgraduate students
Results and Impact Biofortified Zinc Flour to Eliminate Zinc Deficiency in Pakistan (BiZiFED)
Year(s) Of Engagement Activity 2018
 
Description UCLan Health and Wellbeing Blog December 2017 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact UCLan Health and Wellbeing Blog December 2017 entitled: BiZiFED Innovating with Zinc for Healthier Diets in Pakistan. This was an update about objective 2 of the BiZiFED project: A designed field experiment to determine the impact of zinc fertilizers on the yields and grain zinc concentration of biofortified wheat.
Year(s) Of Engagement Activity 2017
URL https://uclanhealthwellbeing.wordpress.com/2017/12/19/bizifed-innovating-with-zinc-for-healthier-die...
 
Description UCLan Health and Wellbeing Blog February 2018 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Media (as a channel to the public)
Results and Impact BiZiFED trial of biofortified zinc flour completed in Pakistan
Year(s) Of Engagement Activity 2018
URL https://uclanhealthwellbeing.wordpress.com/2018/02/22/bizifed-trial-of-biofortified-zinc-flour-compl...
 
Description UCLan Health and Wellbeing Blog July 2018 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Investigating the potential health and economic impact of agronomic biofortification of wheat in Pakistan
Year(s) Of Engagement Activity 2018
URL https://uclanhealthwellbeing.wordpress.com/2018/07/09/investigating-the-potential-health-and-economi...
 
Description UCLan Health and Wellbeing Blog March 2018 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Media (as a channel to the public)
Results and Impact BiZiFED Mid-Project meeting in Pakistan
Year(s) Of Engagement Activity 2018
URL https://uclanhealthwellbeing.wordpress.com/2018/04/05/bizifed-mid-project-meeting-in-pakistan/
 
Description UCLan Health and Wellbeing Blog October 2017 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact UCLan Health and Wellbeing Blog October 2017 entitled: BiZiFED trial of biofortified wheat has begun in Pakistan. This was an update about objective 1 of the BiZiFED project: A double blind, randomised controlled trial to examine whether or not consuming the flour made from biofortified wheat has a beneficial impact on the zinc status of zinc deficient women living in a rural community in North West Pakistan.
Year(s) Of Engagement Activity 2017
URL https://uclanhealthwellbeing.wordpress.com/2017/10/20/bizifed-trial-of-biofortified-wheat-has-begun-...
 
Description UCLan Health and Wellbeing Blog October 2018 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Capacity building by working in partnership with researchers in Pakistan
Year(s) Of Engagement Activity 2018
URL https://www.uclan.ac.uk/about_us/case_studies/bizifed-project-case-study.php