Aligning the Epidemiology of Malnutrition with Food Fortification: Grasp Versus Reach.

Large-scale food fortification (LSFF) has been recognized as one of the most cost-effective interventions to improve the intake of vitamins and minerals and decrease the burden of micronutrient deficiency. Indeed, the simple addition of micronutrients to staple foods, such as wheat, maize and rice, or condiments, including salt and bouillon, has tremendous potential to impact malnutrition. However, most LSFF programs have been poorly designed and have not taken into consideration critical inputs, including current levels of nutrient inadequacy and per capita consumption of different food vehicles when deciding which nutrients to add and at what concentrations. LSFF programs, like some other nutrition interventions, also tend to have low coverage and reach and lack monitoring to measure this and course correct. These program design flaws have resulted in limited effectiveness and have made it difficult to determine how best to harmonize LSFF with other interventions to reduce micronutrient deficiencies, including efforts to enhance dietary diversity, biofortification and supplementation. Furthermore, LSFF has often been touted as a population-based intervention, but in fact has heterogenous effects among sub-groups, particularly those with limited access to or inability to afford fortified foods, as well as those with higher physiological requirements, such as pregnant and lactating women. This article focuses on these limitations and the concerted efforts underway to improve the collection, analysis, and use of data to better plan LSFF programs, track implementation, and monitor coverage and impact. This includes a more sophisticated secondary analysis of existing data, innovations to increase the frequency of primary data collection and programmatically relevant visualizations of data of sub-national estimates. These improvements will enable better use of data to target resources and programmatic efforts to reach those who stand to benefit most from fortification.

The Double-Fortified Salt (Iodized Salt with Iron) Consultation: A Process for Developing Evidence-Based Considerations for Countries.

The addition of iodine to edible salt has been one of the most important public health successes of the past half century, enabling most countries to achieve optimal iodine intake and protect the brains of unborn children from the adverse consequences of iodine deficiency. Salt has been an ideal vehicle for this effort because of its near universal and narrow range of consumption, relative ease of technology for salt iodization, and capacity for virtually all salt producers to add iodine. As a result of the success of salt iodization, there has been growing interest in using salt as a vehicle for other important micronutrients, particularly the addition of iron to iodized salt to produce double-fortified salt (DFS), to combat the persistent problem of iron deficiency and iron deficiency anemia. Because of this growing interest in DFS and the need for a comprehensive review of evidence to support the viability of this intervention, the Iodine Global Network (IGN) initiated a global consultation to gather all available data on different aspects of DFS. IGN identified 4 key areas considered essential to understand for a successful fortification intervention: 1) efficacy and effectiveness, or how well DFS produces a health impact in controlled and real-life settings; 2) technical considerations for production, or what are the minimum requirements to manufacture DFS; 3) program implementation to describe experiences thus far with the delivery of DFS across multiple platforms; and 4) comparison of DFS with other iron fortification efforts to determine the comparative advantage of DFS to improve iron intake and prevent iron deficiency anemia. This preface provides an overview of the DFS Consultation objectives, process, and objectives.

The Unfinished Agenda for Food Fortification in Low- and Middle-Income Countries: Quantifying Progress, Gaps and Potential Opportunities.

Large-scale food fortification (LSFF) is a cost-effective intervention that is widely implemented, but there is scope to further increase its potential. To identify gaps and opportunities, we first accessed the Global Fortification Data Exchange (GFDx) to identify countries that could benefit from new fortification programs. Second, we aggregated Fortification Assessment Coverage Toolkit (FACT) survey data from 16 countries to ascertain LSFF coverage and gaps therein. Third, we extended our narrative review to assess current innovations. We identified 84 countries as good candidates for new LSFF programs. FACT data revealed that the potential of oil/ghee and salt fortification is not being met due mainly to low coverage of adequately fortified foods (quality). Wheat, rice and maize flour fortification have similar quality issues combined with lower coverage of the fortifiable food at population-level (< 50%). A four-pronged strategy is needed to meet the unfinished agenda: first, establish new LSFF programs where warranted; second, systems innovations informed by implementation research to address coverage and quality gaps; third, advocacy to form new partnerships and resources, particularly with the private sector; and finally, exploration of new fortificants and vehicles (e.g. bouillon cubes; salt fortified with multiple nutrients) and other innovations that can address existing challenges.

Current status of vitamin A deficiency and the National Vitamin A Control Program in Nepal: results of the 1998 National Micronutrient Status Survey.

The overall objective of the Nepal Micronutrient Status Survey (NMSS) was to assess the distribution and severity of micronutrient malnutrition, and to measure the progress achieved by different interventions. Data presented in this paper concern the prevalence of vitamin A deficiency (VAD) and the outreach and coverage of the National Vitamin A Supplementation activity. A multi-stage cluster sample design was employed that provided statistically representative data for each of thirteen eco-development strata (because of low population density, the West Mountains, Mid-west Mountains and Far-west Mountains were combined into a single stratum). The design allowed for aggregate estimates to be made at the national and ecological zone level. The survey showed a significant improvement in the status of clinical vitamin A deficiency in Nepal. The prevalence of both Bitot's spots and night-blindness among preschool children decreased from levels observed in surveys conducted in the previous twenty years. However, the prevalence of night-blindness was found to be 5% among women, and over 1% among school-aged children, which indicates that the entire population is vulnerable to VAD. These observations support findings from other surveys that have noted a high prevalence of maternal night-blindness in Nepal. Biochemical data collected as part of the survey indicated a high prevalence of low serum retinol (< 0.70 mumol/l), particularly among preschool children. Almost one of every three children (32.3%) and one of every six women (16.6%) had low serum retinol values. Low serum retinol among preschool children was associated with young age (6-11 months), rural location, wasting, presence of night-blindness and Bitot's spots, and residence in the Terai or Mountains. Similarly, sub-clinical VAD in women was associated with age (less than 20 years), pregnancy, the presence of night-blindness and residence in the Terai or Mountains. In the 42 districts covered by the National Vitamin A Programme (NVAP), more than 87% of preschool children were reached with vitamin A capsules. In addition to this, the National Immunisation Day (NID) provided oral polio vaccine drops to an estimated 95.7% of children 12-59 months. Awareness of the importance of vitamin A was, however, much higher in the NVAP districts than in non-programme districts. As would be expected, clinical VAD was most prevalent among children who had not received vitamin A during the most recent vitamin A capsule distribution. Indeed, the data show that vitamin A capsule receipt among children conferred a 59% protective effect for night-blindness and a 51% effect for Bitot's spots. These results point to significant progress having been achieved by the NVAP and NID capsule distribution activities.

Safety and impact of vitamin A supplementation delivered with oral polio vaccine as part of the immunization campaign in Orissa, India.

A study was carried out in Orissa, India, to evaluate the impact on vitamin A status of vitamin A supplementation integrated with an immunization campaign. Data were collected from a representative sample of 1,811 children, aged 12 to 48 months, at baseline and then at 4 and 16 weeks following implementation of vitamin A supplementation. The primary outcome indicator was serum retinol. The coverage of vitamin A supplementation was 97%. There was a significant decline in the prevalence of Bitot's spots from 2.9% to 1.9% at 4 weeks, but the prevalence increased to 3.6% by 16 weeks. Serum retinol concentrations increased between baseline and 4 weeks (from 0.62 +/- 0.32 to 0.73 +/- 0.23 mumol/L, p < .001) but then decreased to 0.50 +/- 0.19 mumol/l at 16 weeks, which was significantly lower than at baseline (p < .001). The greatest increase in serum retinol from baseline to 4-week follow-up was among children with lowest baseline serum retinol and children with Bitot's spots at baseline. This study demonstrates the short-term benefits of vitamin A supplementation to be significant, especially for those whose status is most compromised. At the same time, the benefit of vitamin A supplementation in this population was transient. The impact of the vitamin A could not be sustained for the full 16 weeks in the study population. This finding calls for exploration of other means to improve vitamin A status, perhaps by adjusting the vitamin A supplementation schedule with more aggressive measures to improve intake of foods rich in bioavailable vitamin A, such as small amounts of animal foods or fortified foods. The study demonstrates the feasibility of integrating vitamin A supplementation with immunization campaigns.