Perceptions and sensory acceptability of a composite dish prepared from high iron and low phytate: iron molar ratio iron biofortified common bean and white-fleshed sweet potato among pregnant women in rural Uganda

doi:10.21203/rs.3.rs-4818539/v1

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Research Article

Perceptions and sensory acceptability of a composite dish prepared from high iron and low phytate: iron molar ratio iron biofortified common bean and white-fleshed sweet potato among pregnant women in rural Uganda

https://doi.org/10.21203/rs.3.rs-4818539/v1

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Background

Globally, iron deficiency anaemia (IDA) disproportionately affects pregnant women due to the increased physiological demands of iron associated with fetal growth and development. However, the highest burden of IDA is on pregnant women who reside in low and middle-income countries (LMICs) because they predominantly consume staple legumes such as conventional common bean (CCB) (Phaseolus vulgaris). Such CCB is either low in iron or rich in iron absorption inhibitors such as phytate and polyphenols. To contribute towards fighting IDA, a high iron biofortified common bean (IBCB) was introduced in Uganda. However, there is limited knowledge about its perceptions and acceptability among pregnant women. This study evaluated the perceptions and sensory acceptability of a high iron-low phytate: iron molar ration dish, WFSP + IBCB (test food) against a low iron-high phytate: iron molar ratio dish, WFSP + CCB (control food) among pregnant women in rural Uganda.

Methods

A total of 104 pregnant women participated in the study. The sensory attributes (taste, colour, aroma, texture, and general acceptability) of the test and control foods were rated using a five-point facial hedonic scale (1 = dislike very much, 2 = dislike, 3 = neutral, 4 = like 5 = like very much). An attribute was acceptable if the participant scored from “like to like very much”. Focus group discussions (FGDs) were conducted to assess participant perceptions about the consumption of WFSP + IBCB during pregnancy. The chi-square test was used to detect the proportion difference for each sensory attribute between WFSP + IBCB and WFSP + CCB, whilst FGD data were analyzed by thematic analysis.

Results

All the sensory attributes were acceptable to the participants and not significantly different between WFSP + IBCB and WFSP + CCB (P > 0.05). The pregnant women had positive perceptions of consuming the WFSP + IBCB dish provided IBCB was accessible, affordable, and feasible to prepare, and its intake provided healthier pregnancy outcomes.

Conclusion

The WFSP + IBCB was accepted by pregnant women, and has the potential to replace WFSP + CCB. Intervention studies are needed to evaluate the effect of IBCB intake on iron status, IDA, and pregnancy outcomes in this study population.

Conventional common bean (CCB)

Iron-biofortified common bean (IBCB)

Perceptions

Pregnant women

Sensory acceptability

White-fleshed sweet potato (WFSP)

Anaemia occurs when the number of healthy red blood cells is insufficient to meet the body’s physiological demands for oxygen and nutrient delivery to the body tissues [1]. Hemoglobin is the primary oxygen-carrying molecule within red blood cells, hence the biomarker for measuring anaemia [1]. Anaemia in pregnancy, defined as hemoglobin of less than 11.0 g/dl is a widely recognized nutrition-related preventable problem with serious consequences for pregnant women and their newborns because it is a leading risk factor for several adverse pregnancy outcomes such as maternal mortality, low birth weight, preterm birth, neonatal anaemia, neonatal deaths [2]. Globally, iron deficiency anaemia (IDA) is the most common form of anaemia that disproportionately affects pregnant women due to the increased physiological demands of iron required for increased red blood cell production and blood volume needed to meet the demands of fetal growth and development observed in pregnancy [3, 4]. Moreover, the progress on anaemia in women of reproductive age WRA (15–49 years) including pregnant women is insufficient to meet the World Health Assembly's global nutrition target to halve anaemia prevalence by 2030 in low and middle-income countries (LMICs), including Uganda [5, 6].

Conventional common bean (CCB), Phaseolus vulgaris is a staple legume usually consumed and available for consumption by pregnant women residing in LMICs such as Uganda [7, 8]. However, CCB is either low in iron or rich in iron absorption inhibitors such as phytate and polyphenols that reduce iron bioavailability in consumers including women [7, 9]. Therefore, the low iron content coupled with high amounts of iron absorption inhibitors inherent in plant-source foods such as common bean has been linked to the 40%-50% prevalence of IDA observed among pregnant women in Uganda [6, 10]. To improve the iron content and reduce iron absorption inhibitors of CCB, iron biofortification of common bean programs were introduced in common bean growing and consuming LMICs including Uganda [7, 11, 12]. Iron biofortification of common beans is a nutrition-sensitive strategy that increases the concentration of iron, in the edible portions of common beans through conventional breeding, fertilizer application, or bioengineering (recombinant DNA technology) to improve the iron status of target consumers [13]. Compared to other nutrition-specific strategies such as industrial fortification and supplementation traditionally used to combat dietary iron deficiency and IDA, iron biofortification is relatively cost-effective because once biofortified seeds are released, the rural poor from LMICs can plant them season after season for sustained consumption [14, 15].

The Recommended Dietary Allowance (RDA) is the average daily dietary intake level that is sufficient to meet the nutrient requirements of nearly all healthy individuals in a particular life stage and gender group. It is worth noting that the RDA for iron among pregnant women is higher at 27 mg/day compared to non-pregnant women at 18 mg/day [16]. To contribute towards achieving the RDA for iron among pregnant women, iron supplementation programs are recommended by the World Health Organization (2016) during the antenatal care (ANC) period. However, adherence to iron supplementation during pregnancy is low, likely due to the related side effects such as constipation and undesirable sensory attributes that are reported by pregnant mothers including those who reside in Uganda [18–20]. Therefore, a continued intake of haem iron-rich animal-source foods (ASF) such as meat and organ meats would be necessary to improve the iron status of pregnant women [21]. However, ASFs are expensive for pregnant women who reside in LMICs [22]. Therefore, they resort to low-iron plant-source foods with high phytate and polyphenols such as common bean [23, 24].

To contribute towards improved iron intake among vulnerable groups such as pregnant women, the government of Uganda through HarvestPlus introduced iron biofortification of common bean [25]. Introducing and consumption of IBCB is increasingly seen as a potential strategy for combating iron deficiency (ID) and IDA among vulnerable populations such as WRA including pregnant women [26]. However, it is worth noting that understanding the acceptability of these biofortified foods is a prerequisite for sustainable consumption of such newly released biofortified foods [27, 28].

In Uganda, a staple dish prepared from a combination of WFSP and CCB (WFSP+CCB) is commonly consumed among WRA including pregnant women [29]. However, a combination of sweet potatoes prepared with CCB is low in iron compared to that prepared with IBCB [30]. If such a combination is habitually eaten, it has the potential to increase the risk of ID and IDA among pregnant women. To contribute toward achieving the RDA for iron and combating ID including IDA among pregnant women in rural Uganda, an iron-rich, low phytate-iron molar ratio dish was prepared from WFSP and IBCB (WFSP+IBCB). Therefore, this study evaluated the perceptions and sensory acceptability of a high iron-low phytate: iron molar ratio, WFSP+IBCB (test composite foods) against the low iron-high phytate: iron molar ratio, WFSP+CCB (control composite foods) among pregnant women in rural Uganda. Findings generated from this study will inform whether a dish of WFSP+IBCB high in iron but low in phytate: iron molar ratio has the potential to replace the conventional dish, WFSP+CCB, which is low in iron, but high in phytate: iron molar ratio among pregnant women in rural Uganda.

Study setting and design

Thisexperimental cross-over sensory acceptability study was conducted in Bwera General Hospital, located in Kasese district, western Uganda. The study was conducted in Kasese district because according to the most recent Uganda Demographic and Health Survey, Kasese is among the districts located in the Tooro region (Western Uganda) with the highest prevalence (over 50%) of anaemia among WRA [31]. Bwera Hospital was specifically chosen because it is a district referral hospital that receives over 500 pregnant women monthly for antenatal care (ANC) services from throughout the district.

Study participants and sample size determination

The study participants were pregnant women who rated the taste, texture, aroma, colour, and overall acceptability of both the taste food and control samples using a five-point facial hedonic scale (1 = dislike very much=1, dislike=2, neutral, 3, like=4 and like very much=5). A participant was considered to accept the composite food if they scored 4 and above (like to like very much). Therefore, the sample size was determined to test the hypothesis that the mean score of the sensory attribute would be 4 and above. The sample size was calculated by use of the statistical considerations for a cross-over study software available at http://hedwig.mgh.harvard.edu/sample_size/js/js_crossover_quant.html. A total of 93 pregnant women were eligible to enter this sensory acceptability crossover study. The probability is 80% that the study will detect a sensory acceptability difference at a two-sided 0.05 significance level if the true difference between WFSP+IBCB and WFSP+CCB is 0.5 units. This is based on the assumption that the within-participant standard deviation of the sensory acceptability characteristic response variable is 1.2. Moreover, a minimum sample size of 60 participants is considered adequate for a valid sensory acceptability study [32].

Sampling procedure

The study participants were recruited by systematic sampling method. In systematic sampling, a number is assigned to every record, and then every n^th record is selected from a list [33]. On average, 40 pregnant women come for postnatal services in Bwera General Hospital every day. This study systematically recruited 12 of 40 pregnant women per day in the ANC clinic of Bwera General Hospital between the 4^th and 25^th of August 2023. The following procedure was followed: Every morning, a list of all the first 40 pregnant women to come for postnatal services was obtained. To this end, 40/12=3. Therefore, every third pregnant woman was recruited. A number from 1 to 3 was chosen at random as a starting point. In this case, number 3 was chosen at random. Therefore, every 3^rd pregnant woman was recruited in the study. That is to say, pregnant women numbered 3,6,9,12,15,18, 21, 24, 27, 30, 33, and 36 were recruited every day until the calculated sample size was reached.

Inclusion and exclusion criteria of study participants

A study participant was included in the study if she was pregnant. A pregnant woman was excluded from the study if she had any form of illness or her pregnancy was in the first trimester. This exclusion criterion was considered because several illnesses may affect sensory variables such as smell and taste in pregnant women [34]. Pregnant women in the first trimester were excluded from the study because severe nausea and vomiting (hyperemesis gravidarum) are highly prevalent in the first trimester [35–37]. Therefore, this could lead to an inaccurate sensory evaluation by pregnant women in the first trimester of pregnancy.

Pilot study

A pilot study is a preliminary step or a smaller-scale investigation that aids in the preparation and adjustment of the main study. The pilot study was conducted to test the feasibility of methods and procedures for the preparation of study foods, sensory evaluation, and focus group discussions (FGDs) for later use in the main study. The village health team members (community health workers) identified seven peer pregnant women from the community to participate in the preparation and cooking of the study foods. The peer pregnant women advised on the common cooking methods used to prepare common beans and sweet potatoes at the household level. For example, they advised that common bean is soaked in water overnight (approximately 8 to 10 hours) before it is boiled and fried for consumption, whilst sweet potato is peeled and cooked by local steaming methods. Moreover, boiling common beans with prior soaking has been demonstrated to have higher iron retention [38]. Therefore, the suggested cooking methods were adopted in the preparation of study composite dishes for sensory evaluation during the main study. The midwives identified 22 pregnant women from the antenatal clinic in Bwera Hospital to participate in the sensory evaluation and focus group discussion (FGD) pilot study.

Twenty pregnant women participated in the sensory evaluation pilot study. A short while later, all the 20 pregnant women who had participated in the sensory evaluation, participated in the pilot FGDs. Two FGDs were conducted during the pilot study and each focus group had 10 pregnant women. The pilot study was conducted one week before the main study. This pilot study was conducted on a different day from the main study to prevent the pilot study participants from participating in the main study. The pilot study established that the majority (98%) of the pregnant women who participated in the pilot study had low literacy levels (did not complete primary school education). This was confirmed by records from the ANC clinic. Knowing the literacy level of the potential study participants guided the main study to modify the sensory evaluation hedonic scale from a seven-point scale to a five-point scale. It is worth noting that longer hedonic scales, such as those with 7 or 9 rating scales, tend to confuse participants with lower literacy levels, while rating scales that are shorter than the five-point scale tend to cause end-point avoidance [39]. As the pilot study venue was too far away from the ANC clinic, a closer alternative venue was identified for the main study. No changes were made to the FGD guide after the pilot study. The pilot study was also used to train research assistants. This helped the research assistants to get acquainted with the implementation of the sensory evaluation questionnaire and focus group discussion guide.

Ingredients for the preparation of the study composite dishes

Composite foods are characterised by being multi-ingredient and include both ready-to-eat products and home-prepared dishes [40]. This study used home-based cooking methods commonly used to prepare common beans and sweet potatoes in Uganda. The control composite dish was WFSP served with CCB (WFSP+CCB). This combination was selected because it is a non-biofortified dish habitually consumed in Uganda and it is characterized by low iron content [30]. The test composite dish was WFSP served with IBCB (WFSP+IBCB). The test composite dish was selected because it had a high IBCB [30]. Figure 1 shows the ingredients used to prepare the control and test composite dishes for the acceptability study.

Figure 1 here:

Preparation of test and control composite dishes

The village health team members (community health workers) identified five expert peer pregnant women from the local community and invited them to Bwera Hospital kitchen to participate in the preparation of the study composite dishes. Expert peer pregnant women were encouraged to prepare the composite dishes using locally acceptable home-based methods used in their household to prepare common beans and sweet potatoes to be consumed by pregnant women. The IBCB (NARO bean 4c) was procured from the National Crops Resources Research Institute (NaCRRI), Namulonge, Uganda [41]. The commonly consumed WFSP (Ebiribwa) and CCB (Nambale) in the community were procured from the local market by expert peer pregnant women who prepared the composite dishes used in the study in the presence of the research assistants.

The peer pregnant women soaked the CCB and IBCB separately overnight (approximately 8 to 10 hours) before cooking them by boiling. The pregnant women chose to boil common beans with prior soaking because they argued that soaking softens common beans to reduce cooking time and saves fuel as reported in a previous Ugandan study [38]. The IBCB and CCB were cooked separately using a local stove (Esigiri) until they were soft and ready for human consumption. The cooking time for CCB and IBCB was approximately 1.5 hours and 2.5 hours, respectively. Expert peer pregnant women prepared WFSP separately by peeling, and washing, followed by steaming. The local method of steaming involved putting 1 liter of tap water into the cooking pot, followed by banana stalks, then banana leaves, in which sweet potato was wrapped before being put onto the hot charcoal stove for steaming. The role of the banana stalk was to create an elevation and separation between the water in the cooking pot from the banana leaves, where the sweet potatoes were wrapped. To this end, when water in the pot boiled, it released steam that vaporized through the banana stalk spaces to heat the banana leaves in which the sweet potatoes were wrapped. The cooking time for WFSP was approximately 35 minutes. The duration of boiling common bean varieties and steaming WFSP was sufficient to soften the plant tissue as assessed by the penetration of the tip of a knife without resistance [38].

Iron, polyphenol, phytate composition, and phytate: iron molar ratio of cooked study common bean

The iron composition of the common bean was analyzed by flame atomic absorption spectroscopy as described elsewhere [30, 38]. The total polyphenol content in common bean was determined by spectrophotometry using the Folin–Ciocalteu method as explained by Rodríguez Madrera et al. (2021). The anion-exchange method was used for the determination of the phytate content as explained by Ma et al. (2005). Triplicate analysis for each cooked common bean variety was conducted to get an average of each iron, polyphenol, and phytate content. Table 1 shows the iron, polyphenol, phytate composition, and phytate: iron molar ratio of the cooked IBCB and CCB used in the preparation of WFSP+IBCB and WFSP+CCB, respectively.

Table 1 here:

Measurement of study variables

Measurement of sensory acceptability

Sensory acceptability was measured by the sensory evaluation method. The sensory evaluation sessions were held in a room with separate, isolated cubicles set up for each panelist. Each panelist received a spoon and a small polystyrene cup containing the control composite dish, approximately 50g of CCB combined with 50g WFSP (WFSP+CCB), and the test composite dish, approximately 50g of IBCB combined with 50g of WFSP (WFSP+IBCB). To prevent pregnant women from making judgments based on labels, the samples were given random numbers as labels. The purpose of this was to ensure that panelists relied solely on their sensory experiences to assess the samples [44]. To achieve this, the samples were randomly labeled with a unique three-digit code obtained from a table of random numbers and were served in a random sequence [44]. The samples were warmed in a microwave oven for 10 seconds on medium heat, before serving. The pregnant women were provided with a cup of water to rinse their palates between evaluating samples. Before each session, the sensory attributes of colour, texture, aroma, taste, and overall acceptance were explained to the panelists (pregnant women). An equally spaced five-point facial hedonic scale with ratings (1=“dislike very much”; 2= “dislike”; 3=“neither like nor dislike”; 4=“like”; 5= “like very much”) was used. It is worth noting that the WRA in the study district have lower literacy levels, with 67% of children dropping out of school before completing ordinary-level education [45]. This coupled with low literacy levels established during the pilot study justifies the use of the five-point rating scale in the study participants [39]. Each sensory attribute was described on the form with an accompanying facial hedonic scale. The ratings of the hedonic scale were verbally explained to the pregnant women in the local language during the sensory evaluation sessions. The participants were asked to rate the acceptance of each attribute by marking the appropriate response on the facial hedonic scale. A sensory attribute was considered acceptable if it was rated as “ like to like very much” Figure 2 shows the flow of sensory acceptability of the study composite dishes.

Figure 2 here:

Measurement of pregnant women’s perceptions

Qualitative data based on perceptions were collected using FGDs and a FGD guide. The FGDs were conducted to explore the pregnant women's perceptions to understand the factors that may motivate them to consume the test composite dish (WFSP+IBCB). The FGDs were conducted about 30 minutes after the sensory evaluation study was completed. All the 94 pregnant women who participated in the sensory evaluation study were eligible to participate in the FGDs. Through established community relationships, four facilitators, experienced in conducting FGDs in the local language (Lhukonzo) were recruited for two days of training in FGD moderation concerning the specifics of this research study following guidelines explained elsewhere [46]. A trained facilitator directed the discussions using an unstructured FGD guide. The FGD guide consisted of a brief explanation of the samples that were tasted during the sensory evaluation as well as the questions for initiating and facilitating the discussion. Guidelines for conducting FGDs with a structured set of open-ended questions were followed, as recommended elsewhere [47]. The open-ended question was “You have participated in the sensory evaluation of WFSP combined with IBCB. What would motivate you to consume the WFSP+IBCB compared to the WFSP+CCB? Furthermore, the facilitators used probes such as “Would you explain further?” and “Would you give an example?” where it was deemed necessary. The FGDs were facilitated in the local language (Lhukonzo) by trained FGD facilitators. A digital voice recorder was used to record the FGDs after participants consented to the use of the voice recorder. A sample size for a FGD between 7 and 12 participants is appropriate for a qualitative nutrition-related study [48]. Therefore, each focus group included 8 to 10 participants. The FGDs were conducted until data saturation was reached. Data saturation means that researchers are not finding any additional or new data from the FGDs [49].

Data analysis

Analysis of quantitative data generated from sensory acceptability measurements

The proportion (percentage) of pregnant women was calculated according to their sensory attribute ratings for the control composite dish (WFSP+CCB) and test composite dish (WFSP+IBCB). A sensory attribute was considered acceptable if it was rated as good to very good by the pregnant women. A binary outcome of yes/no was created for a sensory acceptability variable. A chi-square statistical test was used to test for significant differences in the sensory attributes (taste, colour, aroma, texture, and general acceptability) between the control and test composite dishes. A chi-square test was considered significant at a p-value of less than 0.05. Statistical data analysis was done using STATA, version 15.1.

Analysis of qualitative data generated from focus group discussions

Qualitative data generated from FGDs were analyzed using thematic analysis by following the six steps including familiarization of data, coding of data, generating of themes, reviewing of themes, defining and naming of themes, and writeup [50]. Thematic analysis is a method for identifying, analyzing, and reporting patterns (themes) within data. Instead of starting with predetermined themes based on theory or existing knowledge (deductive thematic analysis), this study used an inductive thematic analysis approach, where the themes were determined by the data itself. Table 2 shows the description of the six steps used during the thematic analysis of data generated from the FGDs as recommended elsewhere [50].

Table 2 here:

Ethical considerations

The study was performed following the ethical standards as laid down in the 1964 Declaration of Helsinki. Ethical approval was granted by the AIDS Support Organisation Research Ethical Committee (Reference number, TASO-2023-252). Informed and signed consent were obtained individually from the pregnant women attending the postnatal clinic of Bwera General Hospital, Kasese district, Western Uganda. Informed consent was taken from legally authorized representatives and/or guardians of all participants who were below 18 years old and those without formal education.

Background characteristics of study participants and composite dishes

A total of 104 eligible pregnant women completed both the sensory evaluation study and FGDs. The mean age of study participants was 24.5 years. Only 29% of the pregnant women had at least completed primary education, while 47% and 53% of the study participants' pregnancies were in the second and third trimesters, respectively. The composite dishes were WFSP+IBCB and WFSP+CCB. Therefore, both dishes were similar in the staple tuber, WFSP, and different in the staple common bean, which was either IBCB or CCB. The iron in the cooked IBCB and CCB used to prepare the study dishes was 9.3mg/100g and 5.1mg/100g, respectively. The phytate: iron molar ratio was 12 and 17 in IBCB and CCB, respectively.

Sensory evaluation and acceptability of study composite dishes

The proportion of participants who scored the study composite dishes using a five-point facial hedonic scaleis shown in Table 3.

Table 3 here:

A high proportion of pregnant women reported that they “liked much” to “liked very much” WFSP+IBCB with regards to colour (99%), texture (98%), aroma (97%), taste (92%), and overall acceptability (96%). Similarly, a high proportion of pregnant women reported that they “liked much” to “liked very much” WFSP+CCB with regards to colour (98%), texture (97%), aroma (97%), taste (93%), and overall acceptability (95%).

Sensory acceptability of the study composite dishes

A sensory attribute was considered acceptable if the pregnant woman scored “like much” to “like very much” on the five-point hedonic facial scale. A binary outcome for sensory acceptability (yes or no) was created for each sensory attribute.Table 4 shows the results from the chi-square test for the association between each sensory attribute of the study composite foods and sensory acceptability.

Table 4 here:

Out of the 104 pregnant women, 103 (99%), 101 (97%), 98 (94%), 94 (90%), and 100 (96%) scored colour, texture, aroma, taste, and general acceptability of WFSP+IBCB as acceptable (“like much” to “like very much”), respectively. In contrast, out of the 104 pregnant women, 102 (98%), 101 (97%), 101 (97%), 96 (92%), and 99 (95%) scored colour, texture, aroma, taste, and general acceptability of WFSP+CCB as acceptable (“like much” to “like very much”), respectively. The chi-square test revealed that there was no significant difference in pregnant mothers’ sensory acceptability for all sensory attributes between WFSP+IBCB and WFSP +CCB (P>0.05)

Perceptions on the consumption of study composite foods

Data saturation was achieved on the nineth FGD. Six key themes emerged reflecting issues that may explain the future consumption of WFSP+IBCB by pregnant women in the study area. These themes included sensory acceptability, feasibility to prepare, availability, affordability, sustainable supply, nutritional value, and health benefits of consuming IBCB with either WFSP or any other staple food.

Sensory acceptability attributes

The majority of pregnant women in the FGDs reported no barriers to choosing either WFSP+IBCB or WFSP+CCB for sensory reasons because both dishes were almost similar in all sensory attributes of colour, aroma, texture, and taste.

“I thought that both dishes were composed of WFSP and CCB. If you had not said that one dish was for WFSP+CCB and the other was for WFSP +IBCB, I wouldn’t have noticed that the two varieties of common bean in either WFSP+IBCB or WFSP+CCB were any different in color, texture, smell and taste” (A woman at 6 months gestation)

Pregnant women wondered why either IBCB or CCB combined with WFSP would have a similar taste, smell, texture, and colour, yet they are quite different varieties of common bean. Therefore, the majority of pregnant women could hardly believe that IBCB was not similar to CBB in all the sensory properties.

“….it is hard to believe that IBCB is different from CCB because both have a similar smell, colour, taste, and texture (A woman at 4 months gestation)

“ ..you wonder why sometimes health workers do not want to tell us the truth. How could someone say that IBCB is a different variety from CCB yet both varieties are similar in smell, colour, taste, and texture” (A woman at 8 months gestation)

“Someone may wonder why we are wasting time on this, we all tasted, touched, saw, and smelt on both IBCB and CCB. I could not find any difference in the two common bean varieties in terms of smell, colour, texture, and taste”

Feasibility to prepare iron biofortified common bean for household consumption

The pregnant women noted they would use the IBCB if they cooked more quickly than CCB, and if they had adequate time and fuel to cook them. Some pregnant women indicated some of the preparation techniques for reducing the cooking time of common bean.

“.. one major problem with common beans is that they take long to cook. You end up using a lot of fuel. I would like to know whether this IBCB variety takes a shorter period to get ready after cooking compared to CCB (A woman at 6 months gestation)

“…. I hate cooking common bean because it consumes a lot of fuel and time to become ready. I would only use IBCB if it cooked faster than the CCB” (A woman at 8 months gestation)

“We realized that IBCB was similar to CCB in all the sensory properties. It is likely that they also have similar cooking times. Trust me, IBCB should be having a long cooking time like CCB” (A woman at 8 months gestation)

“Common bean will always be common bean whether IBCB or CCB variety. All varieties of common beans consume a lot of fuel and hence take a long time to cook. I will never cook common beans unless when I feel I have excess firewood to waste” (A teenager at 8 months gestation)

“ …..buying a half kilogram of common bean is cheaper (3000 Uganda shillings) than buying a half kilogram of beef (6500 Uganda shillings). However, cooking common beans is more costly than cooking beef because you will use fuel worth 5000 Uganda shillings in the former and 1000 Uganda shillings in the latter. Moreover, you will cook common beans for more than 3 hours compared to beef which can be cooked between 30 to 45 minutes. If you calculate the amount of fuel and time needed to prepare common bean compared to beef, common bean is too expensive.

“… you see when you are pregnant, you need to cook fast and rest. However, cooking common beans takes a longer time. This will prevent me from cooking common beans” (A prime gravida teenager at 6 months gestation)

“… no one should ever deceive you about the cooking time of common bean. All common bean varieties whether IBCB or CCB take a long time to cook, nearly 4 to 5 hours to cook. However, there are some techniques that you can use to make common beans softer so that they can cook faster. For example, you can soak them in water overnight for about 8 hours. Trust, me soaked beans will cook faster for 2 hours compared to the non-soaked beans which may cook for 4 to 5 hours” (A gravida 4 at 7 months gestation)

“Besides soaking in water, there is a certain type of salt called “ekisula”. This type of salt softens the common bean. You just get a pinch of salt, “ekisula”, you put it the boiling common bean, within an hour the common beans will be ready for human consumption” (A gravida 3 at 4 months gestation)

Availability of iron biofortified common bean in the market and local farmers

The majority of pregnant women showed interest in knowing either the market where they could purchase the IBCB or the district where the IBCB is grown.

“……… tell us where that IBCB variety can be available to buy it. Are the IBCB varieties available in the same market where we buy the CCB?” (A prime gravida at 6 months gestation)

“ Are these IBCB grown here in our district? If so, in which specific subcounty are they commonly grown in the district? If grown within our district, it can be easy to get them because we can buy directly from the local farmers. You see buying common beans from local farmers can be cheaper compared to someone who buys from the retail market” (A gravida 2 at 7 months gestation)

Affordability of iron biofortified common bean

The pregnant women expressed concern about the affordability of IBCB. The majority noted that they would use IBCB for household consumption if was cheaper to purchase from the local market compared to CCB, or if the cost of producing IBCB in their gardens was affordable.

“How much is the cost of IBCB compared to CCB? Is IBCB cheaper than CCB? I would buy for my household consumption if it is offered at an affordable price from the local market” ( A woman at 4 months gestation)

“… you see we are peasant farmers and most of the food for our household consumption is accessed from our garden. I need to know the cost of the IBCB seeds so that I can plant them season after season. I will plant them if they are either cheaper than the CCB or they are of the same cost as CCB (A woman at 8 months gestation)

“…. growing IBCB would be good, but it might be expensive in the long run if they are easily attacked by pests and diseases or are not drought resistant. To what extent are the IBCB drought and pest-resistant compared to our local CCB?” (A woman at 7 months gestation)

“…those newly introduced genetically modified IBCB varieties are not like our local CCB varieties. I guess that the IBCB varieties are easily attacked by pests compared to the CCB. This means that one will incur more costs on buying pesticides if you grow the IBCB” (A woman at 5 months gestation)

Sustainable supply of iron biofortified common bean

Several pregnant women raised a concern about a sustainable supply of the IBCB in the food supply chain.

“….. I would consume the IBCB if I could find it any time I needed it.. The challenge is to go to the market and you don’t find the IBCB any time you may need to cook it for household consumption ” (A woman at 5 months gestation)

“.. I remember the Ministry of Agriculture officials sensitized us about the benefits of consuming IBCB some 3 years back before I migrated to this district. However, I could not find the IBCB on the local market whenever I wanted them. It would be important that as you introduce these IBCB to us also put effort into ensuring that they are always available on the market season after season so that people can either consume them or grow them in their farm household” (A woman at 8 months gestation)

“… health workers and agricultural extension workers always tend to introduce to us biofortified foods. However, these biofortified foods only appear once on the market when their funded project or programme is running. The sad reality is that when the programme ends, you will never find these biofortified foods again in the local community. I doubt whether this IBCB will be available in our community season after season (A woman at 5 months gestation)

Nutritional value and health benefits for pregnancy outcomes

The majority of mothers suggested that they would consume IBCB if they knew that its nutritional value and health benefits to their pregnancy and birth outcomes were superior to that of CCB.

“…. I will only consider eating IBCB combined with WFSP or any other staple if I know that IBCB has more health benefits for my fetus and myself than CCB. Are there any health benefits of consuming IBCB during pregnancy?” (A prime gravida at 6 months gestation)

“ I don't see any difference in the sensory attributes between WFSP+IBCB and WFSP+CCB. Therefore I would only choose to eat WFSP prepared with IBCB when I am sure that IBCB with improve birth outcomes of my newborn including birth weight and general good health” (A woman at 6 months gestation)

“… I think IBCB has nutrients that have health benefits such as the formation of blood for the pregnant woman and the fetus. Before I migrated to this district, I was sensitized that IBCB has a certain nutrient that helps in the formation of blood. However, I have forgotten the name of the nutrient. Since a pregnant woman needs a lot of blood, I would consume IBCB during pregnancy to increase the amount of my blood (A woman at 5 months gestation)

This study explored pregnant women's perceptions and sensory acceptability of an iron-rich composite dish prepared from a combination of WFSP and IBCB. A combination of WFSP and CCB is commonly consumed in Uganda [30]. However, this combination is low in iron compared to that prepared with IBCB [30]. The iron composition in WFSP + IBCB (test food) and WFSP + CCB (control food) used in this study was 9.3mg/100g and 5.1mg/100g of IBCB, respectively. The RDA for iron among pregnant women is 27mg/day [16]. Therefore, only 290g of IBCB prepared with WFSP would be needed to meet the RDA requirements for iron among pregnant women. In contrast, nearly 530g of CCB prepared with WFSP would be needed to meet the RDA requirements for iron among pregnant women. This suggests that compared to the control, (CCB), a smaller portion of the test dish, IBCB is needed to meet RDA for iron in pregnant women. Nevertheless, meeting the RDA should be interpreted with caution because the IBCB had higher contents of iron absorption inhibitors including polyphenols and phytate compared to CCB (see Table 1). However, inhibition due to phytate on non-heme iron absorption is dose-dependent in human subjects, and therefore, a low phytate: iron molar ratio matches with the high theoretical iron bioavailability [51–53]. Therefore, one could argue that the iron absorption in the study IBCB is likely to be higher compared to that in the CCB because the phytate: iron molar ratio was lower in the former (12:1) compared to the latter (17:1) as shown in Table 1.

Table 1

Iron, polyphenols, phytate, and phytate: iron molar ratio of IBCB and CCB¹
Variable (units)	IBCB/100g	CCB/100g
Iron² (mg)	9.3 ± 0.3	5.1 ± 0.2
Total polyphenols² (mg GAE)	572 ± 10	453 ± 12
Phytate ²(mg)	1321 ± 10	982 ± 20
Phytate: iron molar ratio	12:1	17:1
¹Values are means ± standard deviations based on dry weight
² n = 3 independent analyses

To our knowledge, this is the first attempt to understand the sensory acceptability of IBCB homemade composite dishes prepared from iron-rich IBCB among pregnant women in Uganda. In the present study, the sensory acceptability was high (above 90%) for all the attributes including taste, colour, smell, texture, and general acceptability, and was not significantly different between WFSP either prepared with IBCB or CCB. These findings indicate that the high iron-low phytate: iron molar ratio composite dish, WFSP + IBCB is equally acceptable as the low iron-high phytate: iron molar ratio composite dish, WFSP + CCB. Besides, during FGDs, pregnant women could not believe that IBCB was a different variety from CCB because they could hardly notice any difference in all sensory acceptability attributes between IBCB and CCB. These findings suggest that the iron-rich WFSP + IBCB may have the potential to replace the low-iron dish, WFSP + CCB commonly consumed in Uganda.

Sensory acceptability findings observed in this study have been observed elsewhere among WRA [28, 30, 54, 55]. A recent study conducted among lactating mothers in Uganda has demonstrated that IBCB prepared with a provitamin A rich orange-fleshed sweet potato (OFSP) was equally acceptable as the CCB prepared with WFSP in sensory attributes of aroma, taste, and general acceptability but not in colour, and texture [30]. In the study that involved lactating mothers, the colour of the OFSP + IBCB dish was significantly accepted compared to WFSP + CCB, and this observation was attributed to the attractive yellow colour of OFSP [30]. In contrast, the texture of the WFSP + CCB dish was significantly accepted compared to OFSP + CCB, and this observation was attributed to the soft texture of OFSP which was not liked by the study participants [30]. To this end, the differences in sensory acceptability attributes observed between Buzigi et al. (2024) and the current study could be explained by the OFSP used in the test composite dish versus the control dish prepared with WFSP. It is worth noting that this present study used WFSP as part of the composite dish with either IBCB or CCB for the test or control food, respectively.

In Rwanda, the sensory attributes for the two IBCB varieties were rated higher than those of the CCB among consumers of common bean including WRA [54]. In Guatemala common bean consumers including women equally preferred the IBCB and the CCB varieties, although some minor differences were found in some of the sensory attributes [55]. It is worth noting that the sensory acceptability results observed in the previous studies should be interpreted with caution because the previous studies were conducted in non-pregnant women [28, 30, 54, 55], while the current study was conducted in pregnant women. This is noteworthy because hormonal changes that take place during pregnancy may affect sensory attributes such as smell and taste in pregnant women [35, 56].

During FGDs, pregnant women showed interest in knowing where they could buy IBCB either for growing season after season or for continued HH consumption. These findings may indicate the willingness to pay (WTP) for the IBCB and the possibility of adopting the use of IBCB by the study participants. Similar findings of WTP for IBCB and the possibility of adopting the use of IBCB have been reported among lactating women in rural Uganda [30]. Moreover, the adoption of IBCB has the potential to improve HH consumption of IBCB [57]. In addition, the consumption of IBCB has been shown to improve iron status outcomes such as haemoglobin, ferritin, transferrin saturation, and physical performance among WRA [58–61]. The role of improved iron status biomarkers such as haemoglobin, ferritin, and transferrin saturation during pregnancy has been linked to better pregnancy outcomes such as reduced low birth weight, improved pregnancy haemoglobin, and reduced infant anaemia [62, 63].

Pregnant women had a negative attitude toward the high fuel costs attributed to the long cooking time for common beans, but not WFSP. This finding is consistent with previous studies conducted in Uganda, which showed that consumers were unwilling to prepare common beans because of the high fuel consumption linked to their long cooking time [30, 64]. However, in the FGDs several women revealed that fuel can be saved by reducing the cooking time of common beans by using a certain type of salt and soaking common beans overnight. Similar findings have been reported either in the former [64], or the latter [65]. Pregnant women learned from each other during FGDs about the cooking techniques that can save fuel, which confirms that common bean consumers in Uganda prefer common bean varieties that have a reduced cooking time to save fuel as reported in both Uganda's urban and rural dwellers [66].

Furthermore, pregnant women who participated in FGD indicated that they would consume IBCB prepared with WFSP if they knew that IBCB were nutritious or if eating them would benefit their pregnancy and pregnancy outcomes. There is convincing evidence from intervention studies that consumption of IBCB can improve the nutritional and health benefits such as iron status and hemoglobin levels of WRA [58, 60, 67, 68]. However, these studies were conducted among non-pregnant WRA [58, 60, 67, 68] The positive perceptions of pregnant women toward using IBCB if they knew that they would provide nutritional and health benefits to their pregnancy may inform that there is a need to conduct intervention studies to understand the effect of IBCB consumption on health benefits in pregnant women including pregnancy outcomes such as maternal iron status, hemoglobin levels, and birth weight. When such evidence is generated, it can be incorporated into nutrition education programs for pregnant women.

The high iron - low phytate: iron molar ratio IBCB served with WFSP was equally accepted as the low iron- high phytate: iron molar ratio CCB served with WFSP, suggesting that WFSP + IBCB has the potential to replace WFSP + CCB in the study participants. Pregnant women had positive perceptions of using IBCB if they could cook fast to save fuel and provide pregnancy outcome benefits upon consumption, with stable availability, and affordable prices in the food supply chain. Intervention studies are needed to evaluate the effect of IBCB intake on iron status, IDA, and pregnancy outcomes in this study population.

CCB

Conventional common bean

IBCB

Iron-biofortified common bean

Milligrams

grams

GAE

Garlic acid equivalents

Declarations

Ethics approval and consent to participate

The study was performed following the ethical standards as laid down in the 1964 Declaration of Helsinki. Ethical approval was granted by the Research Ethical Committee at The AIDS Support Organisation Research Ethical Committee (Reference number TASO-2023-252). Informed and signed consent were obtained individually from the pregnant women in the antenatal clinic. Informed consent was taken from legally authorized representatives and/or guardians of all participants who were below 18 years old and those without formal education.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Author information

¹ Department of Community Health & Behavioural Sciences, School of Public Health, College of Health Sciences, Makerere University, P.O. Box 7062 Kampala Uganda; [email protected]

²Department of Dietetics and Human Nutrition, School of Agricultural, Earth and Environmental Sciences, University of KwaZulu-Natal, Private Bag X01, Scottsville 3209, Pietermaritzburg 3201, South Africa; ORCID: https://orcid.org/0000-0003-3161-1050

³Department of Public Health & Nutrition, Faculty of Health Sciences Victoria University, P.O. Box 30866 Kampala Uganda

Funding

This research was funded through the postdoctoral scholarship awarded to Edward Buzigi in the School of Agricultural, Earth, and Environmental Science within the College of Agriculture, Engineering, and Science at the University of Kwa-Zulu Natal, South Africa.

Author Contribution

E.B., K.P, M.S, M.N, and B.M conceptualized the study: E.B wrote the main manuscript text; E.B., K.P., M.S., M.N., and B.M. supervised the study; E.B., K.P., M.S., M.N., and B.M. acquired funding for data collection; E.B. did data analysis; All authors reviewed and edited the published version of the manuscript.

Acknowledgement

The authors thank the pregnant women who participated in the study, village health team members, and the midwives of Bwera Hospital who helped to mobilize the pregnant women to participate in the study.

Data Availability

to protect study participant privacy, the datasets used and/or analyzed in the present study are available from the corresponding author upon reasonable request.

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Tables 1 to 4 are available in the Supplementary Files section.

No competing interests reported.

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Perceptions and sensory acceptability of a composite dish prepared from high iron and low phytate: iron molar ratio iron biofortified common bean and white-fleshed sweet potato among pregnant women in rural Uganda

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