Global Coverage of Mandatory Large-Scale Food Fortification Programs: A Systematic Review and Meta-Analysis.

Food fortification with micronutrients is widely implemented to reduce micronutrient deficiencies and related outcomes. Although many factors affect the success of fortification programs, high population coverage is needed to have a public health impact. We aimed to provide recent global coverage estimates of salt, wheat flour, vegetable oil, maize flour, rice, and sugar among countries with mandatory fortification legislation. The indicators were the proportion of households consuming the: food, fortifiable food (that is, industrially processed), fortified food (to any extent), and adequately fortified food (according to national or international standards). We estimated the number of individuals reached with fortified foods. We systematically retrieved and reviewed all applicable evidence from: published reports and articles from January 2010 to August 2021, survey lists/databases from key organizations, and reports/literature received from key informants. We analyzed data with R statistical package using random-effects meta-analysis models. An estimated 94.4% of households consumed salt, 78.4% consumed fortified salt (4.2 billion people), and 48.6% consumed adequately fortified salt in 64, 84, and 31 countries, respectively. Additionally, 77.4% of households consumed wheat flour, 61.6% consumed fortifiable wheat flour, and 47.1% consumed fortified wheat flour (66.2 million people) in 15, 8, and 10 countries, respectively, and 87.0% consumed vegetable oil, 86.7% consumed fortifiable oil, and 40.1% consumed fortified oil (123.9 million people) in 10, 7, and 5 countries, respectively. Data on adequately fortified wheat flour and vegetable oil and coverage indicators for maize flour, rice, and sugar were limited. There are major data gaps on fortification coverage for most foods except salt. All countries with mandatory fortification programs should generate and use more coverage data to assess program performance and adjust programs as needed to realize their potential to reduce micronutrient deficiencies (PROSPERO CRD42021269364).

Risk factors of anaemia and iron deficiency in Somali children and women: Findings from the 2019 Somalia Micronutrient Survey.

There are limited data on the prevalence of anaemia and iron deficiency (ID) in Somalia. To address this data gap, Somalia's 2019 micronutrient survey assessed the prevalence of anaemia and ID in children (6-59 months) and non-pregnant women of reproductive age (15-49 years). The survey also collected data on vitamin A deficiency, inflammation, malaria and other potential risk factors for anaemia and ID. Multivariable Poisson regressions models were used to identify the risk factors for anaemia and ID in children and women. Among children, the prevalence of anaemia and ID were 43.4% and 47.2%, respectively. Approximately 36% and 6% of anaemia were attributable to iron and vitamin A deficiencies, respectively, whereas household possession of soap was associated with approximately 11% fewer cases of anaemia. ID in children was associated with vitamin A deficiency and stunting, whereas inflammation was associated with iron sufficiency. Among women, 40.3% were anaemic, and 49.7% were iron deficient. In women, ID and number of births were significantly associated with anaemia in multivariate models, and approximately 42% of anaemia in women was attributable to ID. Increased parity was associated with ID, and incubation and early convalescent inflammation was associated with ID, whereas late convalescent inflammation was associated with iron sufficiency. ID is the main risk factor of anaemia in both women and children and contributed to a substantial portion of the anaemia cases. To tackle both anaemia and ID in Somalia, food assistance and micronutrient-specific programmes (e.g. micronutrient powders and iron supplements) should be enhanced.

Complementary Feeding Indicators in Relation to Micronutrient Status of Ghanaian Children Aged 6-23 Months: Results from a National Survey.

BACKGROUND: Optimal complementary feeding is critical for adequate growth and development in infants and young children. The associations between complementary feeding and growth have been studied well, but less is known about the relationship between complementary feeding and micronutrient status. METHODS: Using data from a national cross-sectional survey conducted in Ghana in 2017, we examined how multiple WHO-recommended complementary feeding indicators relate to anemia and the micronutrient status of children aged 6-23 months. RESULTS: In total, 42%, 38%, and 14% of the children met the criteria for minimum dietary diversity (MDD), minimum meal frequency (MMF), and minimum acceptable diet (MAD), respectively. In addition, 71% and 52% of the children consumed iron-rich foods and vitamin A-rich foods, respectively. The prevalence of anemia, iron deficiency (ID), iron deficiency anemia (IDA) and vitamin A deficiency (VAD) was 46%, 45%, 27%, and 10%, respectively. Inverse associations between MMF and socio-economic status were found, and MMF was associated with an increased risk of ID (55%; p < 0.013) and IDA (38%; p < 0.002). CONCLUSION: The pathways connecting complementary feeding and micronutrient status are complex. Findings related to MMF should be further investigated to ensure that complementary feeding programs account for the potential practice of frequent feeding with nutrient-poor foods.

Risk Factors for Anemia and Micronutrient Deficiencies among Women of Reproductive Age-The Impact of the Wheat Flour Fortification Program in Uzbekistan.

Food fortification can be effective in reducing the prevalence of anemia and micronutrient deficiencies. This study assessed risk factors for-and the impact of the wheat flour program in Uzbekistan on-anemia, and iron and folate deficiency (FD) in non-pregnant women (NPW) of reproductive age. National data were analyzed for risk factors using multivariable regression. Additional iron intake from fortified flour was not associated with iron deficiency (ID) and did not result in a significantly different prevalence of anemia regardless of the levels, whereas women with additional folic acid intake had a lower relative risk (RR) of FD (RR: 0.67 [95% CI: 0.53, 0.85]). RR for anemia was greater in women with ID (RR: 4.7; 95% CI: 3.5, 6.5) and vitamin A insufficiency (VAI; RR 1.5; 95% CI: 1.3, 1.9). VAI (RR: 1.4 [95% CI: 1.3, 1.6]) and breastfeeding (RR: 1.1 [95% CI: 0.99, 1.2]) were associated with increased risk of ID, while being underweight reduced the risk (RR: 0.74 [95% CI: 0.58, 0.96]). Breastfeeding (RR: 1.2 [95% CI: 1.1, 1.4]) and inflammation (RR: 1.2 [95% CI: 1.0, 1.3]) increased risk of FD. FD results indicate that the fortification program had potential for impact, but requires higher coverage of adequately fortified wheat flour and a more bioavailable iron fortificant.

Household Coverage with Adequately Iodized Salt and Iodine Status of Nonpregnant and Pregnant Women in Uzbekistan.

Background: Globally, iodine deficiency has been drastically reduced since the introduction of salt iodization programs; nonetheless, many populations remain at-risk for iodine deficiency. This study aimed to assess the iodine status among women of reproductive age in Uzbekistan and to identify factors associated with iodine deficiency, including the availability of adequately iodized salt at the household level. Methods: A cross-sectional household survey was conducted to produce region-specific estimates of the household coverage with adequately iodized salt and iodine status among women for each of the 14 regions in Uzbekistan. Other information, such as socioeconomic status, lactation and pregnancy, residence, age, and consumption of iodine supplements, was also collected. Results: Overall, 36% of 3413 households had adequately iodized salt (iodine concentration >15 ppm [parts per million (mg I/kg salt)]), 20% had inadequately iodized salt (5-14 ppm), and 44% had salt without detectable iodine (<5 ppm). Adequate iodization was found in 33.2% of the 2626 salt samples taken from retail packages labeled as "iodized," 36.5% of the 96 samples taken from retail packages without mention of iodization, and 50.5% of the 674 samples without the original packaging (p < 0.001). The median urinary iodine concentration (UIC) of 140.9 µg/L (95% confidence interval [CI 132.4-150.7]) in nonpregnant nonlactating women indicated adequate iodine status, while for nonpregnant lactating and pregnant women, the median UIC of 112.9 µg/L [CI 99.3-128.4] and 117.3 µg/L [CI 101.8-139.9], respectively, indicated borderline adequacy. Significant differences in UIC (p < 0.001) were found between nonpregnant nonlactating women living in households with adequately iodized salt (UIC 208.9 µg/L), inadequately iodized salt (UIC 139.1 µg/L), and noniodized salt (UIC 89.9 µg/L). Conclusions: Coverage with adequately iodized salt is low in Uzbekistan, and women in households with poorly iodized salt have substantially worse iodine status; claims on packaging about salt iodization do not reflect salt iodine content. This highlights the importance and effectiveness of salt iodization and the need to strengthen this program in Uzbekistan.

Micronutrient Deficiencies, Nutritional Status and the Determinants of Anemia in Children 0-59 Months of Age and Non-Pregnant Women of Reproductive Age in The Gambia.

Data on micronutrient deficiency prevalence, nutrition status, and risk factors of anemia in The Gambia is scanty. To fill this data gap, a nationally representative cross-sectional survey was conducted on 1354 children (0-59 months), 1703 non-pregnant women (NPW; 15-49 years), and 158 pregnant women (PW). The survey assessed the prevalence of under and overnutrition, anemia, iron deficiency (ID), iron deficiency anemia (IDA), vitamin A deficiency (VAD), and urinary iodine concentration (UIC). Multivariate analysis was used to assess risk factors of anemia. Among children, prevalence of anemia, ID, IDA, and VAD was 50.4%, 59.0%, 38.2%, and 18.3%, respectively. Nearly 40% of anemia was attributable to ID. Prevalence of stunting, underweight, wasting, and small head circumference was 15.7%, 10.6%, 5.8%, and 7.4%, respectively. Among NPW, prevalence of anemia, ID, IDA and VAD was 50.9%, 41.4%, 28.0% and 1.8%, respectively. Anemia was significantly associated with ID and vitamin A insufficiency. Median UIC in NPW and PW was 143.1 µg/L and 113.5 ug/L, respectively. Overall, 18.3% of NPW were overweight, 11.1% obese, and 15.4% underweight. Anemia is mainly caused by ID and poses a severe public health problem. To tackle both anemia and ID, programs such as fortification or supplementation should be intensified.

Vitamin A Supplementation Programs and Country-Level Evidence of Vitamin A Deficiency.

Vitamin A supplementation (VAS) programs targeted at children aged 6-59 months are implemented in many countries. By improving immune function, vitamin A (VA) reduces mortality associated with measles, diarrhea, and other illnesses. There is currently a debate regarding the relevance of VAS, but amidst the debate, researchers acknowledge that the majority of nationally-representative data on VA status is outdated. To address this data gap and contribute to the debate, we examined data from 82 countries implementing VAS programs, identified other VA programs, and assessed the recentness of national VA deficiency (VAD) data. We found that two-thirds of the countries explored either have no VAD data or data that were >10 years old (i.e., measured before 2006), which included twenty countries with VAS coverage ≥70%. Fifty-one VAS programs were implemented in parallel with at least one other VA intervention, and of these, 27 countries either had no VAD data or data collected in 2005 or earlier. To fill these gaps in VAD data, countries implementing VAS and other VA interventions should measure VA status in children at least every 10 years. At the same time, the coverage of VA interventions can also be measured. We identified three countries that have scaled down VAS, but given the lack of VA deficiency data, this would be a premature undertaking in most countries without appropriate status assessment. While the global debate about VAS is important, more attention should be directed towards individual countries where programmatic decisions are made.

High Coverage and Utilization of Fortified Take-Home Rations among Children 6-35 Months of Age Provided through the Integrated Child Development Services Program: Findings from a Cross-Sectional Survey in Telangana, India.

The Integrated Child Development Services (ICDS) in the State of Telangana, India, freely provides a fortified complementary food product, Bal Amrutham, as a take-home ration to children 6-35 months of age. In order to understand the potential for impact of any intervention, it is essential to assess coverage and utilization of the program and to address the barriers to its coverage and utilization. A two-stage, stratified cross-sectional cluster survey was conducted to estimate the coverage and utilization of Bal Amrutham and to identify their barriers and drivers. In randomly selected catchment areas of ICDS centers, children under 36 months of age were randomly selected. A questionnaire, constructed from different validated and standard modules and designed to collect coverage data on nutrition programs, was administered to caregivers. A total of 1,077 children were enrolled in the survey. The coverage of the fortified take-home ration was found to be high among the target population. Nearly all caregivers (93.7%) had heard of Bal Amrutham and 86.8% had already received the product for the target child. Among the children surveyed, 57.2% consumed the product regularly. The ICDS program's services were not found to be a barrier to product coverage. In fact, the ICDS program was found to be widely available, accessible, accepted, and utilized by the population in both urban and rural catchment areas, as well as among poor and non-poor households. However, two barriers to optimal coverage were found: the irregular supply of the product to the beneficiaries and the intra-household sharing of the product. Although sharing was common, the product was estimated to provide the target children with significant proportions of the daily requirements of macro- and micronutrients. Bal Amrutham is widely available, accepted, and consumed among the target population in the catchment areas of ICDS centers. The coverage of the product could be further increased by improving the supply chain.

Coverage of Adequately Iodized Salt Is Suboptimal and Rice Fortification Using Public Distribution Channels Could Reach Low-Income Households: Findings from a Cross-Sectional Survey of Anganwadi Center Catchment Areas in Telangana, India.

Food fortification is a cost-effective approach to prevent and control of micronutrient deficiencies in India. A cross-sectional survey of children 0-35 months of age residing in the catchment areas of anganwadi centers in the state of Telangana was conducted to assess the coverage of adequately iodized salt and the potential for rice fortification. Salt samples were collected and tested for iodine concentration using iodometric titration. Information on demographics, household rice consumption, and Telangana's rice sector was collected and interpreted. In households of selected children, 79% of salt samples were found to be adequately iodized. Salt brand and district were significant predictors of inadequately iodized salt. Daily rice consumption among children and women averaged 122 grams and 321 grams per day, respectively. Approximately 28% of households reported consuming rice produced themselves or purchased from a local farmer, 65% purchased rice from a market or shop, 6% got rice from a public distribution system site, and 2% obtained it from a rice mill. In the catchment areas of Telangana's anganwadi centers, there is significant variation in the coverage of adequately iodized salt by district. Future surveys in Telangana should measure the coverage of salt iodization in the general population using quantitative methods. Nonetheless, increasing the adequacy of iodization of smaller salt manufacturers would help achieve universal salt iodization in Telangana. Despite high consumption of rice, our findings suggest that large-scale market-based rice fortification is not feasible in Telangana due to a large proportion of households producing their own rice and highly fragmented rice distribution. Distributing fortified rice via Telangana's public distribution system may be a viable approach to target low-income households, but would only reach a small proportion of the population in Telangana.

The Potential of Food Fortification to Add Micronutrients in Young Children and Women of Reproductive Age - Findings from a Cross-Sectional Survey in Abidjan, Côte d'Ivoire.

Poor micronutrient intakes are a major contributing factor to the high burden of micronutrient deficiencies in Côte d'Ivoire. Large-scale food fortification is considered a cost-effective approach to deliver micronutrients, and fortification of salt (iodine), wheat flour (iron and folic acid), and vegetable oil (vitamin A) is mandatory in Côte d'Ivoire. A cross-sectional survey on households with at least one child 6-23 months was conducted to update coverage figures with adequately fortified food vehicles in Abidjan, the capital of and largest urban community in Côte d'Ivoire, and to evaluate whether additional iron and vitamin A intake is sufficient to bear the potential to reduce micronutrient malnutrition. Information on demographics and food consumption was collected, along with samples of salt and oil. Wheat flour was sampled from bakeries and retailers residing in the selected clusters. In Abidjan, 86% and 97% of salt and vegetable oil samples, respectively, were adequately fortified, while only 32% of wheat flour samples were adequately fortified, but all samples contained some added iron. There were no major differences in additional vitamin A and iron intake between poor and non-poor households. For vitamin A in oil, the additional percentage of the recommended nutrient intake was 27% and 40% for children 6-23 months and women of reproductive age, respectively, while for iron from wheat flour, only 13% and 19% could be covered. Compared to previous estimates, coverage has remained stable for salt and wheat flour, but improved for vegetable oil. Fortification of vegetable oil clearly provides a meaningful additional amount of vitamin A. This is not currently the case for iron, due to the low fortification levels. Iron levels in wheat flour should be increased and monitored, and additional vehicles should be explored to add iron to the Ivorian diet.

In Rwandese Women with Low Iron Status, Iron Absorption from Low-Phytic Acid Beans and Biofortified Beans Is Comparable, but Low-Phytic Acid Beans Cause Adverse Gastrointestinal Symptoms.

BACKGROUND: Phytic acid (PA) is a major inhibitor of iron bioavailability from beans, and high PA concentrations might limit the positive effect of biofortified beans (BBs) on iron status. Low-phytic acid (lpa) bean varieties could increase iron bioavailability. OBJECTIVE: We set out to test whether lpa beans provide more bioavailable iron than a BB variety when served as part of a composite meal in a bean-consuming population with low iron status. METHODS: Dietary iron absorption from lpa, iron-biofortified, and control beans (CBs) (regular iron and PA concentrations) was compared in 25 nonpregnant young women with low iron status with the use of a multiple-meal crossover design. Iron absorption was measured with stable iron isotopes. RESULTS: PA concentration in lpa beans was ∼10% of BBs and CBs, and iron concentration in BBs was ∼2- and 1.5-fold compared with CBs and lpa beans, respectively. Fractional iron absorption from lpa beans [8.6% (95% CI: 4.8%, 15.5%)], BBs [7.3% (95% CI: 4.0%, 13.4%)], and CBs [8.0% (95% CI: 4.4%, 14.6%)] did not significantly differ. The total amount of iron absorbed from lpa beans and BBs was 421 µg (95% CI: 234, 756 µg) and 431 µg (95% CI: 237, 786 µg), respectively, and did not significantly differ, but was >50% higher (P < 0.005) than from CBs (278 µg; 95% CI: 150, 499 µg). In our trial, the lpa beans were hard to cook, and their consumption caused transient adverse digestive side effects in ∼95% of participants. Gel electrophoresis analysis showed phytohemagglutinin L (PHA-L) residues in cooked lpa beans. CONCLUSION: BBs and lpa beans provided more bioavailable iron than control beans and could reduce dietary iron deficiency. Digestive side effects of lpa beans were likely caused by PHA-L, but it is unclear to what extent the associated digestive problems reduced iron bioavailability. This trial was registered at clinicaltrials.gov as NCT02215278.

Review: The potential of the common bean (Phaseolus vulgaris) as a vehicle for iron biofortification.

Common beans are a staple food and the major source of iron for populations in Eastern Africa and Latin America. Bean iron concentration is high and can be further increased by biofortification. A major constraint to bean iron biofortification is low iron absorption, attributed to inhibitory compounds such as phytic acid (PA) and polyphenol(s) (PP). We have evaluated the usefulness of the common bean as a vehicle for iron biofortification. High iron concentrations and wide genetic variability have enabled plant breeders to develop high iron bean varieties (up to 10 mg/100 g). PA concentrations in beans are high and tend to increase with iron biofortification. Short-term human isotope studies indicate that iron absorption from beans is low, PA is the major inhibitor, and bean PP play a minor role. Multiple composite meal studies indicate that decreasing the PA level in the biofortified varieties substantially increases iron absorption. Fractional iron absorption from composite meals was 4%-7% in iron deficient women; thus the consumption of 100 g biofortified beans/day would provide about 30%-50% of their daily iron requirement. Beans are a good vehicle for iron biofortification, and regular high consumption would be expected to help combat iron deficiency (ID).

External mill monitoring of wheat flour fortification programs: an approach for program managers using experiences from Jordan.

The fortification of wheat flour with micronutrients is a common strategy to increase vitamin and mineral intake. While wheat flour mills are often inspected by agencies affiliated with national ministries to ensure compliance with national fortification standards, few countries use data derived from these inspections to construct an external monitoring system for use in program management and evaluation. The primary objective of this paper is to assess the performance of the external monitoring system utilized in Jordan according to the US Centers for Disease Control and Prevention's Updated Guidelines for Evaluating Public Health Surveillance Systems. A secondary objective is to present mill monitoring results from 2009 to 2010 in order to demonstrate the data generated by the system. The review concludes that the data required for the system is representative, simple to collect, and can be collected in a flexible manner. The external monitoring system is acceptable to participating agencies and millers and is stable due to mandatory fortification legislation which provides the legal framework for external monitoring. Data on production of fortified flour and utilization of premix can be provided in a timely manner, but on-site mill monitoring and flour sample collection are more challenging due to resource constraints. The frequent collection of a small number of indicators can provide fortification program managers with timely information with which to base decisions. Jordan's external monitoring system successfully documented the performance of each mill and the entire flour fortification program, and can serve as a model for other national fortification programs considering external monitoring approaches.

Lessons learned from national food fortification projects: experiences from Morocco, Uzbekistan, and Vietnam.

BACKGROUND: Fortification of staple foods has been repeatedly recommended as an effective approach to reduce micronutrient deficiencies. With the increased number of fortification projects globally, there is a need to share practical lessons learned relating to their implementation and responses to project-related and external challenges. OBJECTIVE: To document the achievements, challenges, lessons learned, and management responses associated with national fortification projects in Morocco, Uzbekistan, and Vietnam. METHODS: Independent end-of-project evaluations conducted for each project served as the primary data source and contain the history of and project activities undertaken for, each fortification project. Other sources, including national policy documents, project reports from the Global Alliance for Improved Nutrition (GAIN) and other stakeholders, industry assessments, and peer-reviewed articles, were used to document the current responses to challenges and future project plans. RESULTS: All projects had key achievements related to the development of fortification standards and the procurement of equipment for participating industry partners. Mandatory fortification of wheat flour was a key success in Morocco and Uzbekistan. Ensuring the quality of fortified foods was a common challenge experienced across the projects, as were shifts in consumption patterns and market structures. Adjustments were made to the projects' design to address the challenges faced. CONCLUSIONS: National fortification projects are dynamic and must be continually modified in response to specific performance issues and broader shifts in market structure and consumption patterns.

Implementing large-scale food fortification in Ghana: lessons learned.

BACKGROUND: Food fortification began in Ghana in 1996 when legislation was passed to enforce the iodization of salt. This paper describes the development of the Ghanaian fortification program and identifies lessons learned in implementing fortification initiatives (universal salt iodization, fortification of vegetable oil and wheat flour) from 1996 to date. OBJECTIVE: This paper identifies achievements, challenges, and lessons learned in implementing large scale food fortification in Ghana. METHODOLOGY: Primary data was collected through interviews with key members of the National Food Fortification Alliance (NFFA), implementation staff of the Food Fortification Project, and staff of GAIN. Secondary data was collected through desk review of documentation from the project offices of the National Food Fortification Project and the National Secretariat for the Implementation of the National Salt Iodization in Ghana. RESULTS: Reduction of the prevalence of goiter has been observed, and coverage of households with adequately iodized salt increased between 1996 and 2006. Two models were designed to increase production of adequately iodized salt: one to procure and distribute potassium iodate (KIO3) locally, and the second, the salt bank cooperative (SBC) model, specifically designed for small-scale artisanal salt farmers. This resulted in the establishment of a centralized potassium iodate procurement and distribution system, tailored to local needs and ensuring competitive and stable prices. The SBC model allowed for nearly 157 MT of adequately iodized salt to be produced in 2011 in a region where adequately iodized salt was initially not available. For vegetable oil fortification, implementing quantitative analysis methods for accurate control of added fortificant proved challenging but was overcome with the use of a rapid test device, confirming that 95% of vegetable oil is adequately fortified in Ghana. However, appropriate compliance with national standards on wheat flour continues to pose challenges due to adverse sensory effects, which have led producers to reduce the dosage of premix in wheat flour. CONCLUSIONS: Challenges to access to premix experienced by small producers can be overcome with a central procurement model in which the distributor leverages the overall volume by tendering for a consolidated order. The SBC model has the potential to be expanded and to considerably increase the coverage of the population consuming iodized salt in Ghana. Successful implementation of the cost-effective iCheck CHROMA rapid test device should be replicated in other countries where quality control of fortified vegetable oil is a challenge, and extended to additional food vehicles, such as wheat flour and salt. Only a reduced impact on iron deficiency in Ghana can be expected, given the low level of fortificant added to the wheat flour. An integrated approach, with complementary programs including additional iron-fortified food vehicles, should be explored to maximize health impact.