Firm-Level and Public-Sector Costs Make Small-Scale Maize Flour Fortification Challenging in Uganda.

BACKGROUND: Maize flour in Uganda is milled by hundreds of enterprises, mostly small- (5-20 metric tons [MT]/day) and micro-scale (<5 MT/day) mills or firms. A mandatory maize flour fortification program exists for medium-scale mills (>20 MT/day) and policymakers are considering including smaller-scale millers. OBJECTIVE: We estimated the private and public costs of maize flour fortification at different scales and explored their implications for extending the mandatory fortification to include smaller-scale mills. METHODS: We used secondary data on the structure of the maize flour market and primary data on milling and fortification costs to estimate mill and regulatory costs at 3 scales of flour production: micro, small, and medium. RESULTS: For micro-, small-, and medium-size operations, respectively, operational costs of fortification were US$13, US$9, and US$7 per metric ton (MT) of maize flour, which represented 20%, 16%, and 16% of annual operating costs, and the ratio of fortification equipment cost to mill equipment costs was higher for micro-scale mills (2.7) than for small- (0.38) and medium-scale (0.54) maize mills. Governmental regulatory costs rise if smaller-scale mills are included due to the increased number of facility inspections. CONCLUSIONS: Fortification and regulatory costs increase as production scale decreases. Up-front capital costs of fortification would be daunting for micro- and small-scale mills. Medium-scale mills, which supply social protection programs, might be able to manage fortification costs and other challenges. Decision-makers should consider all costs and cost burdens, and the realities of enforcement capabilities before expanding fortification programs to include smaller-scale operations.

Plain language titleCosts of Small-scale Maize Flour Fortification in UgandaPlain language summaryA study of the costs of adding vitamins and minerals by small-scale maize flour millers in Uganda was undertaken to understand if it would be commercially beneficial from a business and operations perspective for them to do so, and if requiring them to do so would impose additional cost burdens on government to ensure that fortification standards were met.Why was the study done?Maize flour is consumed by the majority of Uganda's population, especially the rural poor. If the flour were fortified, it would reduce vitamin and mineral deficiencies among those at risk. The most important constraint to market-wide fortification is the presence of many small-scale mills or firms that neither have the resources nor the technology to adopt and sustain the fortification process. To date, no study has been done to calculate the costs that small-scale mills would have to face to fortify flour, or what the cost implications for government would be for including smaller-scale mills in a national fortification program, including the costs of enforcing regulations.What did the researchers do?The researchers interviewed millers of several scales of operation to collect cost information on their operations and interviewed representatives of government regulatory bodies to estimate the costs of testing maize flour to ensure compliance with regulations. Researchers estimated the cost to the mills of adding fortification to their business models, and the impacts on the government costs (eg, testing additional samples, etc.) of including smaller-scale mills in the fortification program.What did the researchers find?The researchers looked at 3 different types of mills based on their capacity to mill maize flour­micro-scale firms milled less than 5 metric tons (MT) a day, small-scale firms milled 5 to 20 MT per day, and medium-scale firms milled over 20 MT a day. For micro-, small-, and medium-size firms, respectively, fortification increased operational costs by US$13, US$9, and US$7 per MT of maize flour, which represented 20%, 16%, and 16% of annual operating costs. Similarly, governmental regulatory costs rose if smaller-scale mills were included because of the increased number of facility inspections required since the current legislation requires mandatory annual inspections.What do the findings mean?Fortification and regulatory costs increase as the scale of production by the millers decreases. If fortification by small- and micro-scale mills were made mandatory, up-front costs of fortification equipment and materials would be daunting for micro- and small-scale millers. Ugandan medium-scale millers might manage fortification costs and other challenges, but only if the social protection programs they supplied were of sufficient volume and regularity.

Potential of Vitamin D Food Fortification in Prevention of Cancer Deaths-A Modeling Study.

Meta-analyses of randomized controlled trials (RCTs) have estimated a 13% reduction of cancer mortality by vitamin D supplementation among older adults. We evaluated if and to what extent similar effects might be expected from vitamin D fortification of foods. We reviewed the literature on RCTs assessing the impact of vitamin D supplementation on cancer mortality, on increases of vitamin D levels by either supplementation or food fortification, and on costs of supplementation or fortification. Then, we derived expected effects on total cancer mortality and related costs and savings from potential implementation of vitamin D food fortification in Germany and compared the results to those for supplementation. In RCTs with vitamin D supplementation in average doses of 820-2000 IU per day, serum concentrations of 25-hydroxy-vitamin D increased by 15-30 nmol/L, respectively. Studies on food fortification found increases by 10-42 nmol/L, thus largely in the range of increases previously demonstrated by supplementation. Fortification is estimated to be considerably less expensive than supplementation. It might be similarly effective as supplementation in reducing cancer mortality and might even achieve such reduction at substantially larger net savings. Although vitamin D overdoses are unlikely in food fortification programs, implementation should be accompanied by a study monitoring the frequency of potentially occurring adverse effects by overdoses, such as hypercalcemia. Future studies on effectiveness of vitamin D supplementation and fortification are warranted.

Regulation and Consumer Interest in an Antioxidant-Enriched Ham Associated with Reduced Colorectal Cancer Risks.

An economic experiment was conducted in France in 2020 to evaluate consumer attitudes toward two ham products associated with different colorectal cancer risks. We focused specifically on comparing a conventional ham and a new hypothetical antioxidant-enriched ham with a reduced risk of provoking colorectal cancer. Study participants were given descriptions of the two hams before carrying out successive rounds of willingness-to-pay (WTP) assessments. The results show that WTP was higher for the antioxidant-enriched ham than for the conventional ham. WTP estimates were also impacted by providing additional information about the reduction in colorectal cancer risk associated with the antioxidant-enriched ham. Based on the participants' WTP, we came up with ex ante estimates for the social impacts of introducing the antioxidant-enriched ham onto the market, and we suggest that it would be socially optimal to promote the product. Competition arising from pre-existing product labelling and marketing assertions could greatly limit the market potential of antioxidant-enriched ham, which suggests that alternative approaches may be necessary, such as regulations mandating antioxidant enrichment. These results also concern all countries with high levels of meat consumption.

The Impact of Micronutrient Fortified Foods on Cognitive Functioning among Low-Income Children: A Pilot and Feasibility Study.

Brain development continues throughout childhood and requires micronutrients for optimal maturation, but studies have typically examined only a limited number of micronutrients and there has been inconsistent use of validated cognitive measures. This study evaluated the impact of providing low-income children with a daily fortified meal (570 kcal) in the form of a bar and shake containing >75% of the FDA Daily Values for all essential vitamins and minerals, as well as macronutrients (e.g., omega-3 and omega-6 fatty acids and protein), in an afterschool care setting (instead of the usual meal provided) on cognitive functioning. Students aged 8-12 were randomly assigned to intervention (n = 19) or control (n = 16) meals. Students completed the Stroop Color Word Task, Trail Making Test, and Conner's Continuous Performance Task (CPT) at baseline and 3 months post-intervention. Differences in cognitive scores were examined using 2 × 2 mixed model ANOVAs (Stroop and CPT) and ANCOVAs (Trail Making Test). Significant main effects of time indicated improvements in both intervention and control groups, but there were no significant main effects of group or group*time interactions. When the amount of meal consumed was examined, most results became non-significant, suggesting that overall meal consumption significantly impacted the observed results. Overall, this pilot study suggests that there may be limited additional benefits to short-term consumption of micronutrient fortified meals among low-income children in an afterschool care setting, and potential benefits observed may be directly related to the amount of food consumed.

An Estimation of Price Effects of Making Food Fortification Mandatory in India.

BACKGROUND: Despite several interventions, India has made little progress in reducing hidden hunger, micronutrient malnutrition. Food fortification of staple foods could be useful in addressing the above problem. Nonetheless, it may lead to an increase in economic stress among people by increasing inflation and monthly budget expenditure. OBJECTIVE: The prime objective was to see whether or not mandatory food fortification will lead to an increase in inflation and the family's budget expenditure. METHODS: The study was based on secondary data. Decomposition approach has been used-inflation was decomposed into contributions of each commodity and which was further divided into base, weight, and inflation effects. To estimate the impact of mandatory food fortification on the family's budget expenditure, monthly per capita expenditure has been assessed by considering both the situations-with and without fortification. RESULTS: Results suggest that mandatory food fortification has a very negligible effect on inflation, suggesting no rise in inflation due to mandatory food fortification in India. Also, the study suggests a minimal increase in monthly per capita expenditure in both rural and urban sectors of India. CONCLUSIONS: Though adopting mandatory food fortification in India will not have an impact on inflation, there would be 2 major challenges: high dependency on food items processed locally and unawareness of benefits of fortified food items. Therefore, the government can first start food fortification of staple food with safety nets programs like NFSA, focusing on the most vulnerable groups of the society, and then scale up at a large scale.

Consumer Acceptance and Willingness to Pay for Instant Cereal Products With Food-to-Food Fortification in Eldoret, Kenya.

BACKGROUND: Maize is the major food staple in East and Southern Africa, where food-processing industries are emerging fast. New low-cost extrusion cookers allow small enterprises to enter the market for processed cereals, including instant, fortified, and flavored products. OBJECTIVE: Assess consumers' interest and preferences for the new products. METHODS: Consumers (n = 220) in Eldoret, Kenya, were invited to evaluate 4 new cereal products: (1) sifted maize flour mixed with sorghum, (2) instant sifted mixed flour, (3) instant whole flour, and (4) instant whole flour fortified with natural ingredients and to compare them to conventional sifted maize flour, using 2 preparations: stiff porridge (ugali) and soft porridge (uji). These were followed by economic experiments to estimate consumers' willingness to pay (WTP) for the new products and traits. RESULTS: For ugali, consumers preferred conventional sifted maize flour, while for uji, they appreciated the new products, especially sifted mixed flour (with sorghum) and instant whole mixed flour. Fortification with food-to-food sources was not appreciated, especially for ugali. Comparing WTP for the traits with their production cost showed that mixed, whole, and instant flours were economical, but not fortification. Maize/sorghum mixtures realized a benefit of 24% over conventional maize flour, whole meal 11%, and instant mixtures 5%. CONCLUSIONS: There is a potential market for improved cereal products in Kenya, but more for uji than for ugali, especially with instant, mixed, and whole flour. Acceptable and affordable products, fortified with other foods that are locally available, however, still need to be developed, especially for ugali.

Are Low-Income Consumers Willing to Pay for Fortification of a Commercially Produced Yogurt in Bangladesh.

BACKGROUND: There is an active debate over the potential for market-based strategies to address micronutrient deficiencies in low- and middle-income countries. However, there are questions over the viability of market-based strategies, reflecting limited evidence on the value that low-income households attach to the nutritional attributes of processed foods. OBJECTIVE: The objective of this article is to investigate the willingness to pay of primary food purchasers in low-income households in rural Bangladesh for Shokti+, a nutritionally fortified yogurt produced and distributed by Grameen Danone Foods Limited. METHODS: A real choice experiment with economic incentives was conducted with 1000 rural food purchasers sampled from the distribution area of Shokti+ in rural Bangladesh. The choices of respondents revealed attribute nonattendance, favoring the fortification attribute over price. RESULTS: Results from a random parameter logit model found that respondents were willing to pay an average of 18 BDT (US$0.22) for fortification and 6 BDT (US$0.073) for brand name. The market price for Shokti+ at the time of the study was 10 BDT (US$0.12). The results from a random effects model suggest the magnitude of willingness to pay for fortification was primarily driven by the nutritional awareness of respondents but offset by household food insecurity. CONCLUSIONS: The article concludes that, while there is a viable market for fortified yogurt in rural Bangladesh, efforts to promote this product as a strategy to address micronutrient deficiency are best targeted at low-income households with some capacity to pay for low priced commercially produced foods.

Optimizing the Use of Human Milk Cream Supplement in Very Preterm Infants: Growth and Cost Outcomes.

BACKGROUND: An exclusive human milk-based diet has been shown to decrease necrotizing enterocolitis and improve outcomes for infants ≤1250 g birth weight. Studies have shown that infants who received an exclusive human milk diet with a donor-human milk-derived cream supplement (cream) had improved weight and length velocity when the cream was added to mother's own milk or donor-human milk when energy was <20 kcal/oz using a human milk analyzer. Our objective was to compare growth and cost outcomes of infants ≤1250 g birth weight fed with an exclusive human milk diet, with and without human milk cream, without the use of a human milk analyzer. METHODS: Two cohorts of human milk-fed premature infants were compared from birth to 34 weeks postmenstrual age. Group 1 (2010-2011) received a donor-human milk fortifier, whereas Group 2 (2015-2016) received donor-human milk fortifier plus the commercial cream supplement, if weight gain was <15 g/kg/d. RESULTS: There was no difference in growth between the 2 groups for weight (P = 0.32) or head circumference (P = 0.90). Length velocity was greater for Group 1 (P = 0.03). The mean dose of donor-human milk fortifier was lower in Group 2 (P < 0.001). Group 2 saved an average of $2318 per patient on the cost of human milk products (P < 0.01). CONCLUSIONS: Infants receiving a human milk diet with cream supplementation for growth faltering achieve appropriate growth in a cost-effective feeding strategy.

The economic case for prevention of population vitamin D deficiency: a modelling study using data from England and Wales.

BACKGROUND: Vitamin D deficiency (VDD) affects the health and wellbeing of millions worldwide. In high latitude countries such as the United Kingdom (UK), severe complications disproportionally affect ethnic minority groups. OBJECTIVE: To develop a decision-analytic model to estimate the cost effectiveness of population strategies to prevent VDD. METHODS: An individual-level simulation model was used to compare: (I) wheat flour fortification; (II) supplementation of at-risk groups; and (III) combined flour fortification and supplementation; with (IV) a 'no additional intervention' scenario, reflecting the current Vitamin D policy in the UK. We simulated the whole population over 90 years. Data from national nutrition surveys were used to estimate the risk of deficiency under the alternative scenarios. Costs incurred by the health care sector, the government, local authorities, and the general public were considered. Results were expressed as total cost and effect of each strategy, and as the cost per 'prevented case of VDD' and the 'cost per Quality Adjusted Life Year (QALY)'. RESULTS: Wheat flour fortification was cost saving as its costs were more than offset by the cost savings from preventing VDD. The combination of supplementation and fortification was cost effective (£9.5 per QALY gained). The model estimated that wheat flour fortification alone would result in 25% fewer cases of VDD, while the combined strategy would reduce the number of cases by a further 8%. CONCLUSION: There is a strong economic case for fortifying wheat flour with Vitamin D, alone or in combination with targeted vitamin D3 supplementation.

A Fortified Food Can Be Replaced by Micronutrient Supplements for Distribution in a Mexican Social Protection Program Based on Results of a Cluster-Randomized Trial and Costing Analysis.

BACKGROUND: Despite positive nutrition impacts, the prevalence of malnutrition among beneficiaries of Mexico's conditional cash transfer (CCT) program remains high. Greater nutrition impact may have been constrained by the type of nutritional supplements provided. OBJECTIVE: The objective of this study was to inform a potential modification to the supplements distributed to pregnant and lactating women and children. METHODS: Impact was assessed using 2 cluster-randomized trials (pregnant women, children) run simultaneously. Communities (n = 54) were randomly assigned to the fortified foods provided by the program (Nutrivida women, Nutrisano children) or alternatives: tablets (women), syrup (children), or micronutrient powders for women (MNP-W) and children (MNP-C). Each supplement for women/children contained the same micronutrients based on the formulations of Nutrivida and Nutrisano, respectively. Pregnant women (aged >18 y) were recruited before 25 weeks of gestation and followed to 3 mo postpartum. Children aged 6-12 mo were recruited and followed to age 24 mo. Primary outcomes were anemia for women and length growth for children. Statistical analyses appropriate for cluster-randomized designs were used, and structural equation modeling to estimate dose-response effects. Supplement costs per beneficiary (daily dose for 18 mo) were estimated for production and distribution. RESULTS: There was no significant difference in change of anemia prevalence between supplement groups in women, or in length growth between groups in children. One daily dose of any supplement was associated with 0.8 cm greater length growth. From baseline to age 24 mo, the prevalence of anemia in the Nutrisano, syrup, and MNP-C groups decreased by 36.7, 40.8, and 37.9 percentage points, respectively (within-group, P < 0.05; between groups, P > 0.05). Costs per beneficiary ranged from $12.1 (MNP-C) to $94.8 (Nutrivida). CONCLUSIONS: The CCT program could distribute alternative supplements at lower cost per beneficiary without compromising potential for impact. Acceptance among beneficiaries should also be considered in choice of alternatives. This trial was registered at www.clinicaltrials.gov as NCT00531674.

An economic analysis of human milk supplementation for very low birth weight babies in the USA.

BACKGROUND: An exclusive human milk diet (EHMD) using human milk based products (pre-term formula and fortifiers) has been shown to lead to significant clinical benefits for very low birth weight (VLBW) babies (below 1250 g). This is expensive relative to diets that include cow's milk based products, but preliminary economic analyses have shown that the costs are more than offset by a reduction in the cost of neonatal care. However, these economic analyses have not completely assessed the economic implications of EHMD feeding, as they have not considered the range of outcomes affected by it. METHODS: We conducted an economic analysis of EHMD compared to usual practice of care amongst VLBW babies in the US, which is to include cow's milk based products when required. Costs were evaluated from the perspective of the health care payer, with societal costs considered in sensitivity analyses. RESULTS: An EHMD substantially reduces mortality and improves other health outcomes, as well as generating substantial cost savings of $16,309 per infant by reducing adverse clinical events. Cost savings increase to $117,239 per infant when wider societal costs are included. CONCLUSIONS: An EHMD is dominant in cost-effectiveness terms, that is it is both cost-saving and clinically beneficial, for VLBW babies in a US-based setting.

The Role of Health Information in Consumers' Willingness to Pay for Canned Crushed Tomatoes Enriched with Lycopene.

The paper investigated whether information about the health benefit produced by lycopene could influence consumers' willingness to pay (WTP) for canned crushed tomatoes enriched with lycopene. An additional aim was to determine whether the main socio-demographic variables, such as sex, age, income and selected attitudinal factors, affect WTP. To this end, a non-hypothetical experimental auction was carried on with five repeated rounds. Results show a relevant impact of information on WTP in the case of lycopene-enriched products, whereas no difference in bids emerges for the conventional product, either on average or at the quantiles. Previous knowledge seems to have a modest influence upon WTP, but it shows a significant interaction with the information shock provided during the experiment, so that the effect of the latter is more pronounced when previous knowledge is low. In addition, age, sex, food technology neophobia, trust in science and implicit attitudes towards food technology significantly affect participants' WTP.

Technology for Triple Fortification of Salt with Folic Acid, Iron, and Iodine.

As many of the maternal and child health complications result from folic acid, iron, and iodine deficiencies; it makes sense to combat these simultaneously. We have developed cost-effective technology to deliver these three micronutrients simultaneously through salt. Our goal was to retain at least 70% of the micronutrients during 6 months of storage. The fortified salt was formulated by spraying a solution that contained 2% iodine and 0.5% or 1% folic acid onto salt and adding encapsulated ferrous fumarate. The formulated triple fortified salt contained 1,000 ppm iron, 50 ppm iodine, and 12.5 or 25 ppm folic acid. The spray solution and the salt were stored for 2 and 6 months respectively at 25, 35, and 45 °C 60 to 70% relative humidity. Even at 45 °C, over 70% of both iodine and folic acid were retained in the salt. The best formulation based on the color of the salt and stability of iodine and folic acid contained 12.5 ppm folic acid, 50 ppm iodine, and 1,000 ppm iron. These results indicate that iron, iodine, and folic acid can be simultaneously delivered to a vulnerable population through salt using the technology described. Also, the quality control of the process can be developed around pteroic acid that was detected as a primary degradation product of folic acid. PRACTICAL APPLICATION: The technology developed is already transferred to India for industrial scale up. When fully operational, the technology will simultaneously solve iron, iodine, and folic acid deficiencies in vulnerable populations at a very low cost.

Nutrient Cost-Effectiveness of Fortified Blended Food Aid Products.

BACKGROUND: Sorghum-Soy Blend (SSB) and Sorghum-Cowpea Blend (SCB) fortified blended food aid porridge products were developed as alternatives to Corn-Soy Blend Plus (CSB+) and Super Cereal Plus (SC+), the most widely used fortified blended food aid products. However, the cost and nutrient cost-effectiveness of these products procured from different geographical areas have not been determined. OBJECTIVE: The objective of this study is to determine the nutrient cost-effectiveness of SSB and SCB compared to existing fortified blended foods. METHODS: Nutritional data as well as ingredient, processing, and transportation cost for SSB, SCB, and existing fortified blended foods were compiled. Using the omega value, the ratio of the fortified blended food's Nutrient Value Score to the total cost of the fortified blended food divided by an identical ratio of a different fortified blended food or the same fortified blended food produced in a different country and the nutrient cost-effectiveness of each of the fortified blended foods procured in the United States and several African countries were determined. RESULTS: Both CSB+ and SC+ are less expensive than SSB and SCB, but they also have lower Nutrient Value Scores of 7.7 and 8.6, respectively. However, the omega values of CSB+ and SC+ are all above 1 when compared to SSB and SCB, suggesting that the existing fortified blended foods are more nutrient cost-effective. CONCLUSIONS: Comparing the nutrient cost-effectiveness of various food aid products could provide valuable information to food aid agencies prior to making procurement decisions.

Cost-effectiveness of sunflower oil fortification with vitamin A in Tanzania by scale.

In 2011, Tanzania mandated the fortification of edible oil with vitamin A to help address its vitamin A deficiency (VAD) public health problem. By 2015, only 16% of edible oil met the standards for adequate fortification. There is no evidence on the cost-effectiveness of the fortification of edible oil by small- and medium-scale (SMS) producers in preventing VAD. The MASAVA project initiated the production of sunflower oil fortified with vitamin A by SMS producers in the Manyara and Shinyanga regions of Tanzania. A quasi-experimental nonequivalent control-group research trial and an economic evaluation were conducted. The household survey included mother and child pairs from a sample of 568 households before the intervention and 18 months later. From the social perspective, the incremental cost of fortification of sunflower oil could be as low as $0.13, $0.06, and $0.02 per litre for small-, medium-, and large-scale producers, respectively, compared with unfortified sunflower oil. The SMS intervention increased access to fortified oil for some vulnerable groups but did not have a significant effect on the prevention of VAD due to insufficient coverage. Fortification of vegetable oil by large-scale producers was associated with a significant reduction of VAD in children from Shinyanga. The estimated cost per disability-adjusted life year averted for fortified sunflower oil was $281 for large-scale and could be as low as $626 for medium-scale and $1,507 for small-scale producers under ideal conditions. According to the World Health Organization thresholds, this intervention is very cost-effective for large- and medium-scale producers and cost-effective for small-scale producers.

Household coverage of vitamin A fortification of edible oil in Bangladesh.

Mandatory fortification of edible oil (soybean and palm) with vitamin A was decreed in Bangladesh in 2013. Yet, there is a dearth of data on the availability and consumption of vitamin A fortifiable oil at household level across population sub-groups. To fill this gap, our study used a nationally representative survey in Bangladesh to assess the purchase of fortifiable edible oil among households and project potential vitamin A intake across population sub-groups. Data is presented by strata, age range and poverty-the factors that potentially influence oil coverage. Across 1,512 households, purchase of commercially produced fortifiable edible oil was high (87.5%). Urban households were more likely to purchase fortifiable oil (94.0%) than households in rural low performing (79.7%) and rural other strata (88.1%) (p value: 0.01). Households in poverty were less likely to purchase fortifiable oil (82.1%) than households not in poverty (91.4%) (p <0.001). Projected estimates suggested that vitamin A fortified edible oil would at least partially meet daily vitamin A estimated average requirement (EAR) for the majority of the population. However, certain population sub-groups may still have vitamin A intake below the EAR and alternative strategies may be applied to address the vitamin A needs of these vulnerable sub-groups. This study concludes that a high percentage of Bangladeshi population across different sub-groups have access to fortifiable edible oil and further provides evidence to support mandatory edible oil fortification with vitamin A in Bangladesh.

Real-World Cost Effectiveness of Mandatory Folic Acid Fortification of Bread-Making Flour in Australia.

BACKGROUND: In 2009, mandatory folic acid fortification of bread-making flour was introduced in Australia to reduce the birth prevalence of preventable neural tube defects (NTDs) such as spina bifida. Before the introduction of the policy, modelling predicted a reduction of 14-49 NTDs each year. OBJECTIVE: Using real-world data, this study provides the first ex-post evaluation of the cost effectiveness of mandatory folic acid fortification of bread-making flour in Australia. METHODS: We developed a decision tree model to compare different fortification strategies and used registry data to quantify the change in NTD rates due to the policy. We adopted a societal perspective that included costs to industry and government as well as healthcare and broader societal costs. RESULTS: We found 32 fewer NTDs per year in the post-mandatory folic acid fortification period. Mandatory folic acid fortification improved health outcomes and was highly cost effective because of the low intervention cost. The policy demonstrated improved equity in outcomes, particularly in birth prevalence of NTDs in births from teenage and indigenous mothers. CONCLUSIONS: This study calculated the value of mandatory folic acid fortification using real-world registry data and demonstrated that the attained benefit was comparable to the modelled expected benefits. Mandatory folic acid fortification (in addition to policies including advice on supplementation and education) improved equity in certain populations and was effective and highly cost effective for the Australian population.

Reductions in child mortality by preventing spina bifida and anencephaly: Implications in achieving Target 3.2 of the Sustainable Development Goals in developing countries.

BACKGROUND: There is an opportunity to reduce child mortality by preventing folic acid-preventable spina bifida and anencephaly (FAP SBA) in developing countries. We estimated reductions in FAP SBA-associated child mortality in 69 countries with an immediate potential for mandatory fortification of wheat flour. METHODS: Using data from multiple sources, we estimated the percent reductions in neonatal, infant, and under-five mortality that would have occurred by preventing FAP SBA; and the contributions of these reductions toward each country's Sustainable Development Goals (SDG) for child mortality reduction. We used the combined prevalence of spina bifida and anencephaly in selected countries before fortification, and estimated preventable child mortality associated with FAP SBA, assuming 0.5 per 1,000 live births as minimum achievable prevalence from mandatory fortification. RESULTS: Annually, 56,785 live births with FAP SBA occurred in the 69 countries examined. Of these, about 49,680 (87%) would have resulted in deaths under age 5 years, and are preventable through mandatory folic acid fortification. On average, compared to current rates, prevention of FAP SBA would have reduced the neonatal, infant, and under-five mortality by 19% (95% uncertainty interval [UI]: 16-24%), 15% (UI: 13-17%), and 14%, (95% UI: 13-17%), respectively. Prevention of FAP SBA seemed to contribute toward achieving SDG on neonatal and under-five mortality in developing countries. CONCLUSIONS: Prevention of FAP SBA will lead to notable and immediate reductions in child mortality. Many countries have an opportunity to effectively move toward child mortality-related SDG targets with existing milling infrastructure for food fortification.

Evaluación de dos fórmulas de yogur enriquecido con harina de Acheta domesticus y harina de Brosimum alicastrum Swartz como alimentos complementarios / Evaluation of two formulas of yogurt enriched with Acheta domesticus flour and Brosimum alicastrum flour, as complementary foods

La prevalencia de desnutrición en niños en Guatemala es constante y se ha mantenido alta por años. Tomando en cuenta esta problemática se planteó un modelo de alimentación complementaria a base de yogur enriquecido con harinas de alto valor proteico en niños de edad preescolar en el suroccidente de Guatemala. Los tratamientos evaluados fueron yogur con harina de Acheta domesticus (grillo), yogur con harina de Brosimum alicastrum Swartz (ramón) y un grupo control. Se evaluó el peso, talla y velocidad de crecimiento durante cuatro meses brindando 125 mL de yogur cinco días por semana. La ganancia media (desviación estándar) de peso en kg fue de 3.21 (1.84), 2.22 (1.14) y 1.67 (0.64) para A. domesticus, B. alicastrum y grupo control, respectivamente. Mostrando la mezcla de yogur con harina de A. domesticus diferencia significativa frente al control (p < .05), por el contrario, no se encontró diferencia significativa (p > .05) cuando se comparó con yogur con harina de B. alicastrum. Para el incremento en talla en cm los resultados fueron 4.61 (1.13), 4.25 (1.54) y 3.07 (1.84) para A. domesticus, B. alicastrum y grupo control, respectivamente, mostrando ambas diferencias significativas frente al control (p < .05). Se determinaron los costos por dosis los cuales fueron US$0.56 (A. domesticus) y US$0.36 (B. alicastrum). Se concluye que el yogur con harina de A. domesticus fue el que presentó mejor respuesta en las variables de estudio.

The prevalence data on malnutrition of children in Guatemala are constant. Taking into account this problem, a yogurt-based supplementary feeding model was proposed, enriched with high-protein flours in pre-school children in southwestern Guatemala. The treatments evaluated were yogurt with Acheta domesticus flour (cricket), yogurt with Brosimum alicastrum Swartz flour (ramon) and control group. The weight, height and growth rate were evaluated during four months providing 125 mL of yogurt five days per week. The weight gain in kg was 3.21 (1.84), 2.22 (1.14) and 1.67 (0.64) for A. domesticus, B. alicastrum and control group respectively, showing significant difference (p < .05). The costs per dose were determined, which were US $ 0.56 (A. domesticus) and US $ 0.36 (B. alicastrum). The study concludes that yogurt with A. domesticus flour was the one that presented the best response in the study variables.

The Availability and Nutritional Adequacy of Gluten-Free Bread and Pasta.

Management of coeliac disease (CD) requires the removal of gluten from the diet. Evidence of the availability, cost, and nutritional adequacy of gluten-free (GF) bread and pasta products is limited. GF flours are exempt from UK legislation that requires micronutrient fortification of white wheat flour. This study surveyed the number and cost of bread and pasta products available and evaluated the back-of-pack nutritional information, the ingredient content, and the presence of fortification nutrients of GF bread and pasta, compared to standard gluten-containing equivalent products. Product information was collected from four supermarket websites. Standard products were significantly cheaper, with more products available than GF (p < 0.05). GF bread products were significantly higher in fat and fiber (p < 0.05). All GF products were lower in protein than standard products (p < 0.01). Only 5% of GF breads were fortified with all four mandatory fortification nutrients (calcium, iron, niacin, and thiamin), 28% of GF breads were fortified with calcium and iron only. This lack of fortification may increase the risk of micronutrient deficiency in coeliac sufferers. It is recommended that fortification legislation is extended to include all GF products, in addition to increased regulation of the nutritional content of GF foods.