Guideline: fortification of wheat flour with vitamins and minerals as a public health strategy

This guideline provides locally adaptable, clear, evidence-informed global recommendations on the fortification of wheat flour with vitamins and minerals as a public health strategy to improve the micronutrient status of populations, which are grounded in gender, equity and human rights approaches with the aim of leaving no one behind. The focus of this document is on the use of this intervention as a public health strategy and not on market-driven fortification of wheat flour or products. This guideline aims to help Member States and their partners to make informed decisions on the appropriate nutrition actions to achieve the 2030 Sustainable Development Goals and the global targets set in the World Health Organization (WHO) comprehensive implementation plan on maternal, infant and young child nutrition. The recommendations in this guideline are intended for a wide audience, including policymakers, expert advisers, and technical and programme staff in ministries and organizations involved in the design, implementation and scaling-up of nutrition actions for public health. The recommendations are particularly relevant to the design and implementation of appropriate food-fortification programmes, as part of a comprehensive food-based strategy for combating micronutrient inadequacies and deficiencies. These recommendations supersede the previous WHO recommendation on the fortification of wheat flour.

Iron salts and vitamins: use, purchase and sources of obtainment among children in Brazil.

To verify the prevalence of use, purchase and sources of iron salts and vitamins by children aged from 0 to 12 years in Brazil. Population-based transversal study (Brazilian National Survey on Access, Utilization, and Promotion of Rational Use of Medicines - PNAUM), including 7,528 children up to 12 years of age. Information was obtained through questionnaires answered by the children's tutors, about the use of iron salts and vitamins 15 days before the interview; forms of financing, and sources of obtainment, sociodemographic characteristics, and presence of chronic disease. Descriptive and bivariate analyses were performed and the main variables were expressed by relative frequencies and 95% confidence intervals (95%CI). The prevalence of use of iron salts was 1.6% (95%CI: 1.2-2.1), with higher prevalence among children under 1 year old (8.5%; 95%CI: 6.3-11.5) and residents of the southeastern region (2.3%; 95%CI: 1.5-3.4). Prevalence of use of vitamins was 4.8% (95%CI: 4.2-5.6), with higher prevalence among children under 1 year old (24.3%; 95%CI: 20.3-28.7) and residents of the northern region (8.6%; 95%CI: 6.2-11.7). Purchase occurred by direct reimbursement for 41.6% (95%CI: 27.9-56.7) of the iron salts, and for 82.4% (95%CI: 76.3-87.2) of the vitamins. The iron salts were predominantly obtained from SUS pharmacies (51.5%; 95%CI: 36.4-66.4), and the vitamins from commercial pharmacies (80.6%; 95%CI: 77.4-85.6). The results suggested the use of iron salts in the Brazilian pediatric population was low, with reduction in use as age increased, regional differences and free-of-charge obtainment, predominantly from SUS.

Iron salts and vitamins: use, purchase and sources of obtainment among children in Brazil / Sais de ferro e vitaminas: uso, aquisição e fontes de obtenção para crianças brasileiras / Sales de hierro y vitaminas: uso, adquisición y fuentes de obtención entre niños en Brasil

To verify the prevalence of use, purchase and sources of iron salts and vitamins by children aged from 0 to 12 years in Brazil. Population-based transversal study (Brazilian National Survey on Access, Utilization, and Promotion of Rational Use of Medicines - PNAUM), including 7,528 children up to 12 years of age. Information was obtained through questionnaires answered by the children's tutors, about the use of iron salts and vitamins 15 days before the interview; forms of financing, and sources of obtainment, sociodemographic characteristics, and presence of chronic disease. Descriptive and bivariate analyses were performed and the main variables were expressed by relative frequencies and 95% confidence intervals (95%CI). The prevalence of use of iron salts was 1.6% (95%CI: 1.2-2.1), with higher prevalence among children under 1 year old (8.5%; 95%CI: 6.3-11.5) and residents of the southeastern region (2.3%; 95%CI: 1.5-3.4). Prevalence of use of vitamins was 4.8% (95%CI: 4.2-5.6), with higher prevalence among children under 1 year old (24.3%; 95%CI: 20.3-28.7) and residents of the northern region (8.6%; 95%CI: 6.2-11.7). Purchase occurred by direct reimbursement for 41.6% (95%CI: 27.9-56.7) of the iron salts, and for 82.4% (95%CI: 76.3-87.2) of the vitamins. The iron salts were predominantly obtained from SUS pharmacies (51.5%; 95%CI: 36.4-66.4), and the vitamins from commercial pharmacies (80.6%; 95%CI: 77.4-85.6). The results suggested the use of iron salts in the Brazilian pediatric population was low, with reduction in use as age increased, regional differences and free-of-charge obtainment, predominantly from SUS.

O estudo teve como objetivo verificar a prevalência do uso, aquisição e fontes de saís de ferro e vitaminas para crianças entre 0 e 12 anos de idade no Brasil. Foi realizado um estudo transversal de base populacional (Pesquisa Nacional sobre Acesso, Utilização e Promoção do Uso Racional de Medicamentos - PNAUM), incluindo 7.528 crianças até 12 anos de idade. As informações foram obtidas através de questionários respondidos pelos pais ou responsáveis, sobre o uso de sais de ferro e vitaminas nos 15 dias anteriores à entrevista; formas de financiamento e fontes de aquisição, características sociodemográficas e presença de doenças crônicas. Foram realizadas análises descritivas e bivariadas, e as principais variáveis foram expressas como frequências relativas com intervalos de 95% de confiança (IC95%). A prevalência do uso de sais de ferros foi 1,6% (IC95%: 1,2-2,1), com prevalência maior entre crianças com menos de 1 ano de idade (8,5%; IC95%: 6,3-11,5) e residentes da Região Sudeste (2,3%; IC95%: 1,5-3,4). A prevalência do uso de vitaminas foi 4,8% (IC95%: 4,2-5,6), com prevalência maior entre crianças com menos de 1 ano (24,3%;IC95%: 20,3-28,7) e residentes da Região Norte (8,6%; IC95%: 6,2-11,7). A aquisição ocorreu por reembolso direto em 41,6% (IC95%: 27,9-56,7) dos sais de ferro e em 82,4% (IC95%: 76,3-87,2) das vitaminas. Os sais de ferro foram adquiridos predominantemente através das farmácias do SUS (51,5%; IC95%: 36,4-66,4), e as vitaminas em farmácias comerciais (80,6%; IC95%: 77,4-85,6). Os resultados sugerem que o uso de sais de ferro na população pediátrica brasileira é por baixo, com uma redução no uso conforme aumenta a idade da criança, além de diferenças regionais e aquisição gratuita, predominantemente do SUS.

Este trabajo tiene el fin de verificar la prevalencia de uso, adquisición y fuentes de sales de hierro y vitaminas por parte de niños desde 0 a 12 años de edad en Brasil. Se trata de un estudio transversal, basado en población (Encuesta Nacional sobre el Acceso, Uso y Promoción de Uso Racional de Medicinas - PNAUM por sus siglas en portugués), que incluye a 7.528 niños de hasta 12 años de edad. La información se obtuvo a través de cuestionarios respondidos por los tutores de los niños, sobre el uso de sales de hierro y vitaminas 15 días antes de la entrevista; formas de financiación, y fuentes de adquisición, características sociodemográficas, y presencia de alguna enfermedad crónica. Se realizaron análisis descriptivos y bivariados, además las variables principales se plasmaron mediante frecuencias relativas e intervalos del 95% de confianza (IC95%). La prevalencia del uso de sales de hierro fue de un 1,6% (IC95%: 1,2-2,1), con una prevalencia más alta entre niños por debajo de un 1 año de edad (8,5%; IC95%: 6,3-11,5) y residentes de la Región sudeste (2,3%; IC95%: 1,5-3,4). La prevalencia del uso de vitaminas fue de un 4,8% (IC95%: 4,2-5,6), con una prevalencia más alta con niños menores de 1 año de edad (24,3%; IC95%: 20,3-28,7) y residentes de la Región nordeste (8,6%; IC95%: 6,2-11,7). La adquisición tuvo lugar por reembolso directo en un 41,6% (IC95%: 27,9-56,7) de sales de hierro, y por un 82,4% (IC95%: 76,3-87,2) de las vitaminas. Las sales de hierro se obtuvieron predominantemente en farmacias del SUS (51,5%; IC95%: 36,4-66,4), y las vitaminas en farmacias comerciales (80,6%; IC95%: 77,4-85,6). Los resultados sugirieron el consumo de las sales de hierro en la población pediátrica brasileña fue por bajo, con una reducción en su consumo a medida que la edad aumentaba, además de diferencias regionales, y su obtención gratuita, predominantemente del SUS.

Trends in Vitamin A, C, D, E, K Supplement Prescriptions From Military Treatment Facilities: 2007 to 2011.

INTRODUCTION: Although prior studies have examined the prevalence of dietary supplement use among various populations, data on single vitamins prescribed by health care providers are limited. OBJECTIVE: This study examined trends in single-vitamin supplement (A, C, D, E, K) prescriptions by providers from military treatment facilities from 2007 to 2011. METHODS: We examined prescription data from the Department of Defense Pharmacy Data Transaction Service to determine trends in the aforementioned single-vitamin supplement prescriptions. Prescription rates per 1,000 active duty personnel were estimated using population data retrieved from the Defense Medical Epidemiology Database (i.e., [number of prescriptions/population size] × 1,000). RESULTS: Across the 5-year period, the number of vitamin D prescriptions per 1,000 active duty personnel increased 454%. In contrast, the number of vitamin A, vitamin E, and vitamin K prescriptions per 1,000 active duty personnel decreased by 32%, 53%, and 29% respectively. Vitamin C prescriptions remained relatively constant. Across all age groups, total single-vitamin supplement prescriptions increased by 180%. CONCLUSION: Together, prescriptions examined in this study increased steadily from 2007 to 2011, primarily because of the increase in vitamin D prescriptions. The exhibited trend reflects the current general-population pattern of dietary supplement use, with large increases in vitamin D and declines in vitamin E.

Health care use amongst online buyers of medications and vitamins.

BACKGROUND: With increased use of the internet, more people access medications and health supplements online. However little is known about factors associated with using online buying. Given the variable quality of online pharmacies, an important question is whether online consumers also have health care providers with whom they discuss internet information and decisions. OBJECTIVES: To help address these gaps this study used the Andersen Model to explore (1) the characteristics of internet buyers of medicines and/vitamins, (2) the association between health care use and buying medicines and/vitamins online drawing on the Andersen health care utilization framework, and (3) factors predicting discussion of internet information with health providers. METHODS: The National Cancer Institute's Health Information National Trends Survey (HINTS) 2007 was analyzed to study online medication buying among a national sample of internet users (N = 5074). The Andersen Model of health care utilization guided the study's variable selection and analyses. Buying online and talking about online information are the two main outcome variables. Separate multivariate logistic regression analyses identified factors associated with online buying and factors predicting discussions with providers about online information. RESULTS: In 2007, 14.5% (n = 871) of internet users bought a medication or vitamin online. About 85% of online buyers had a regular provider, but only 39% talked to the provider about online information even though most (93.7%) visited the provider ≥1 times/year. Multivariate analyses found internet health product consumers were more likely to be over 50 years old, have insurance and discuss the internet with their provider than non-internet health product consumers. Moreover, discussion of internet information was more likely if consumers had a regular provider and perceived their communication to be at least fair or good in general. CONCLUSIONS: There is a clear association of online buying with age, frequency of visits and discussing online information with a provider. Although most online buyers visited a provider in the prior year, only a minority discussed the internet with them. This suggests a missed opportunity for providers to help patients navigate internet buying, particularly if they are a patient's regular provider and the patient perceives their communication as good.

A qualitative study of uptake of free vitamins in England.

OBJECTIVE: To identify reasons why eligible families are not accessing free 'Healthy Start' vitamin supplementation (providing vitamins A, C and D) in England. DESIGN: Qualitative study using in-depth interviews. SETTING: 13 primary care trusts in England. PARTICIPANTS: Purposive sample of 15 Healthy Start coordinators, 50 frontline health and children's professionals and 107 parents. RESULTS: Vitamin take-up was low across all research sites, reported as below 10% of eligible beneficiaries for free vitamins. Reasons identified by both parents and professionals included (1) poor accessibility of vitamins, (2) low promotion of the scheme by health professionals, (3) a lack of awareness among eligible families, and (4) low motivation among mothers to take vitamins for themselves during pregnancy or for children under 4 years old. CONCLUSIONS: Low uptake rates can be explained by poor accessibility of vitamins and lack of awareness and motivation to take vitamin supplements among eligible families. Universal provision (at least for pregnant women) and better training for health professionals are identified as potential solutions worthy of further research and evaluation.

Does lack of multinutrient supplementation during early pregnancy increase vulnerability to alcohol-related preterm or small-for-gestational-age births?

The objective of this study was to assess whether women who do not take multinutrient supplements during early pregnancy are more susceptible to the effects of low-to-moderate alcohol consumption on preterm birth and small-for-gestational-age birth (SGA) compared to women who do take multinutrients. This analysis included 800 singleton live births to mothers from a cohort of pregnant women recruited for a population-based cohort study conducted in the Kaiser Permanente Medical Care Program in Northern California. Participants were recruited in their first trimester of pregnancy and information about their alcohol use and supplement intake during pregnancy was collected. Preterm birth (n=53, 7%) was defined as a delivery prior to 37 completed weeks of gestation and SGA birth (n=124, 16%) was defined as birth weight less than the 10th percentile for the infant's gestational age and sex compared to US singleton live births. A twofold increase in the odds of SGA birth attributed to low-to-moderate alcohol intake was found among multinutrient supplement non-users (95% CI: 1.1, 5.3). Yet, among multinutrient supplement users, there was no increased risk of an SGA birth for women who drank low-to-moderately compared to women who abstained (aOR: 0.97, 95% CI: 0.6, 1.6). Similar results emerged for preterm birth. Our findings provide marginal evidence that multinutrient supplementation during early pregnancy may modify the risk of SGA births and preterm birth associated with alcohol consumption during pregnancy and may have important implications for pregnant women and women of child-bearing age. However, future research needs to be conducted.

An audit of health products advertised for sale on chiropractic Web sites in Canada and consideration of these practices in the context of Canadian chiropractic codes of ethics and conduct.

OBJECTIVE: This study describes the extent to which chiropractors with Web sites practicing in Canada advertise health products for sale and considers this practice in the context of chiropractic codes of ethics and conduct. METHODS: Chiropractic Web sites in Canada were identified using a public online business directory (Canada 411). The Web sites were searched, and an inventory of the health products for sale was taken. The influences of type of practice and province of practice on the sale of health product were assessed. Textual comments about health product marketing were summarized. National and provincial codes of ethics were reviewed, and the content on health product advertising was summarized. RESULTS: Two hundred eighty-seven Web sites were reviewed. Just more than half of the Web sites contained information on health products for sale (n = 158, 54%). Orthotics were advertised most often (n = 136 practices, 47%), followed by vitamins/nutritional supplements (n = 53, 18%), pillows and supports (n = 40, 14%), and exercise/rehabilitation products (n = 20, 7%). Chiropractors in solo or group chiropractic practices were less likely to advertise health products than those in multidisciplinary practice (P < .001), whereas chiropractors in BC were less likely to advertise nutritional supplements (P < .01). Provincial codes of ethics and conduct varied in their guidelines regarding health product sales. CONCLUSIONS: Variations in codes of ethics and in the proportions of practitioners advertising health products for sales across the country suggest that opinions may be divided on the acceptability of health product sales. Such practices raise questions and considerations for the chiropractic profession.

Is daily mvi required in patients receiving parenteral nutrition?

Between November 1996 and January 1999 there was a nationwide shortage of intravenous multivitamins (MVI) in the US. We investigated whether patients who received parenteral nutrition (PN) with MVI three times per week instead of daily developed clinical manifestations of vitamin deficiency during that period. Five patients were enrolled in the study All received home PN as their sole source of nutrition for at least six months. None of these patients showed clinical manifestations of vitamin deficiency. In addition, compared to daily MVI administration, supplementation with MVI three times per week saved $1,000 per patient per year. This preliminary study raises the question of how much MVI is needed to prevent vitamin deficiency. Using MVI three days a week instead of daily would substantially reduce the cost of treatment and might reduce the risk of infections for these patients.

Wernicke encephalopathy and beriberi during total parenteral nutrition attributable to multivitamin infusion shortage.

OBJECTIVE: Wernicke encephalopathy (WE) is an acute neurologic disorder characterized by a triad of ophthalmoplegia, ataxia, and mental confusion. WE is attributable to thiamine (vitamin B1) deficiency. Beriberi is the systemic counterpart of thiamine deficiency and often manifests in cardiovascular collapse. WE is usually associated with alcoholism and malnutrition. It has also been seen in people with gastrointestinal diseases with malabsorption. Patients who have received total parenteral nutrition (TPN) without proper replacement of thiamine have also developed WE. Since November 1996, there has been a shortage of multivitamin infusion (MVI). Many patients who were on chronic TPN with MVI ceased to receive the MVI and were converted to an oral form of the multivitamin. As a result, there have been several reports of children and adults on TPN who have developed WE as a result of thiamine deficiency. With this case report, we bring to attention the association of the MVI shortage and WE. Early diagnosis of WE is important, because if it is treated with thiamine in the acute stages, the neurologic and cardiovascular abnormalities can be reversed. CASE REPORT: We report a 20-year-old female patient with Crohn's disease who developed WE as a result of thiamine deficiency. She had Crohn's disease since age 9 years and was on chronic TPN. Two months before admission, MVI was discontinued in the TPN because of the shortage of its supply. An oral multivitamin tablet was substituted instead. She was admitted to the hospital for persistent vomiting. In the hospital, she continued to receive TPN without MVI, but continued taking an oral multivitamin preparation. Two weeks after admission, she developed signs of WE including diplopia, ophthalmoplegia, nystagmus, and memory disturbance. She also developed hypotension that was thought to be caused by beriberi. She was treated with 50 mg of intravenous thiamine. Within hours of the intravenous thiamine, her hypotension resolved. The day after the infusion, she no longer complained of diplopia, and her ophthalmoplegia had improved dramatically. Magnetic resonance imaging showed several areas of abnormally high signal on T2-weighted images in the brainstem, thalamus, and mamillary bodies. The topographic distribution of these changes was typical of WE. After 2 months, her mental status and neurologic status had recovered completely. CONCLUSION: WE and thiamine deficiency should be considered in all patients with malabsorption, malnutrition, and malignancies. WE from thiamine deficiency can occur as a result of cessation of MVI in the TPN infusion. Even if an oral multivitamin preparation is given instead of MVI, patients with malabsorption may not absorb thiamine adequately. Prompt diagnosis of WE is important because it is potentially fatal and readily treatable with thiamine supplementation. Early recognition of WE may be more difficult in children, because the classic triad of symptoms may not develop fully. Magnetic resonance imaging may be useful in these cases to confirm the diagnosis of WE. Because the shortage of MVI is expected to be a long-term, there are likely to be more cases of WE in the pediatric population of TPN-dependent children. Because there is no shortage of intravenous thiamine, it should be administered with TPN even if MVI is not available.

Lactic acidosis traced to thiamine deficiency related to nationwide shortage of multivitamins for total parenteral nutrition -- United States, 1997.

Since November 1996, there has been a nationwide shortage of intravenous (IV) multivitamins (MVIs) used in U.S. hospitals and home-health-care agencies for total parenteral nutrition (TPN). Patients receiving TPN without MVI supplementation are at risk for thiamine deficiency and life-threatening complications associated with severe deficiency of thiamine, a coenzyme necessary for oxidation of keto acids (Figure 1). This report describes three patients receiving TPN who had thiamine deficiency-related lactic acidosis in 1997 and presents recommendations for alternatives to parenteral MVI during the shortage.