Maternal anaemia prevention and control in China: A policy review.

Maternal anaemia is a major public health problem. Developing maternal anaemia prevention and control policies is an important prerequisite for carrying out evidence-based interventions. This article reviews maternal anaemia prevention and control policies in China, identifies gaps, and provides references for other countries. We examined policies concerning maternal nutrition and other related literature in China, identified through key databases and government websites, and conducted a narrative review of the relevant documentations guided by the Smith Policy-Implementing-Process framework. A total of 65 articles and documents were identified for analysis. We found that Chinese government has committed to reducing maternal anaemia at the policy level, with established objectives and a clear time frame. However, most of policies were not accompanied by operational guidelines, standardized interventions, and vigorous monitoring and evaluation mechanisms, and 85% of the policies don't have quantifiable objectives on anaemia. Maternal anaemia prevention and control services offered in clinical settings were primarily nutrition education and anaemia screening. Population-based interventions such as iron fortification have yet to be scaled up. Furthermore, medical insurance schemes in some regions do not cover anaemia prevention and treatment, and in other regions that offer coverage, the reimbursement rate is low. The number and capacity of health professionals is also limited. Policy changes should focus on the integration of evidence-based interventions into routine antenatal care services and public health service packages, standardization of dosages and provision of iron supplementation, streamline of reimbursement for outpatient expenses, and capacity building of health professionals.

Beyond Nutrient Deficiency-Opportunities to Improve Nutritional Status and Promote Health Modernizing DRIs and Supplementation Recommendations.

The US Dietary Guidelines for Americans (DGA) provide dietary recommendations to meet nutrient needs, promote health, and prevent disease. Despite 40 years of DGA, the prevalence of under-consumed nutrients continues in the US and globally, although dietary supplement use can help to fill shortfalls. Nutrient recommendations are based on Dietary Reference Intakes (DRIs) to meet the nutrient requirements for nearly all (97 to 98 percent) healthy individuals in a particular life stage and gender group and many need to be updated using current evidence. There is an opportunity to modernize vitamin and mineral intake recommendations based on biomarker or surrogate endpoint levels needed to 'prevent deficiency' with DRIs based on ranges of biomarker or surrogate endpoints levels that support normal cell/organ/tissue function in healthy individuals, and to establish DRIs for bioactive compounds. We recommend vitamin K and Mg DRIs be updated and DRIs be established for lutein and eicosapentaenoic and docosahexaenoic acid (EPA + DHA). With increasing interest in personalized (or precision) nutrition, we propose greater research investment in validating biomarkers and metabolic health measures and the development and use of inexpensive diagnostic devices. Data generated from such approaches will help elucidate optimal nutrient status, provide objective evaluations of an individual's nutritional status, and serve to provide personalized nutrition guidance.

Designing an Effective Front-of-Package Warning Label for Food and Drinks High in Added Sugar, Sodium, or Saturated Fat in Colombia: An Online Experiment.

Policies to require warnings on the front of food and drinks high in nutrients of concern (e.g., added sugar, sodium, or saturated fat) are becoming increasingly common as an obesity prevention strategy. Colombia, a country with growing prevalence of obesity, is considering implementing a similar policy. The objective of this study was to assess perceptions and reactions to different warning designs. We conducted a randomized experiment in an online panel of adults age > 18y (n = 1997). Participants were randomized to view one of four labels: a control label (barcode), an octagon warning, a circle warning, and a triangle warning. Participants viewed their randomly assigned label on a series of products and answered questions (continuous outcomes ranged from 1-4). Compared to the control, all warnings led to higher perceived message effectiveness (increase in mean from 1.79 in the control to 2.59-2.65 in the warning conditions, p < 0.001), a higher percentage of participants who correctly identified products high in nutrients of concern (from 48% in the control condition to 84-89% in the warning conditions, p < 0.001), and reduced intentions to purchases these products (decrease in mean from 2.59 to 1.99-2.01 in the warning conditions, p < 0.001). Relative to the control, warnings performed similarly across education levels, suggesting this policy would be equitable in Colombia. Looking at differences by warning type, the pattern of results suggested that the octagon warnings performed best. After viewing all label types, 49% of participants selected the octagon warning as the one that most discouraged them from consuming products high in nutrients of concern, while 21% and 27% selected the circle and triangle warning. Colombian policymakers should consider the octagon warning as part of a front-of-package labeling policy to help consumers identify and reduce consumption of foods and drinks high in nutrients of concern.

Regulatory and Policy-Related Aspects of Calcium Fortification of Foods. Implications for Implementing National Strategies of Calcium Fortification.

Daily calcium intake is well below current recommendations in most low- and middle-income countries (LMICs). Calcium intake is usually related to bone health, however an adequate calcium intake has also been shown to reduce hypertensive disorders of pregnancy, lower blood pressure and cholesterol values, and to prevent recurrent colorectal adenomas. Food fortification of foods has been identified as a cost-effective strategy to overcome micronutrient gaps in public health. This review summarizes regulatory aspects of fortification of commonly consumed foods with micronutrients, with an emphasis on calcium. We selected a convenient sample of 15 countries from different WHO regions and described the regulatory framework related to calcium fortification of staple foods. We assessed the relevant policies in electronic databases including the WHO Global database on the Implementation of Nutrition Action (GINA) for fortification policies and the Global Fortification Data Exchange Database, a fortification database developed and maintained by Food Fortification Initiative (FFI), Global Alliance for Improved Nutrition (GAIN), Iodine Global Network (IGN), and Micronutrient Forum. Food fortification with micronutrients is widely used in many of the selected countries. Most countries had national legislation for the addition of micronutrients to staple foods, especially wheat flour. These national legislations, that includes regulations and standards, can provide the framework to consider the implementation of adding calcium to the fortification strategies, including the selection of the adequate food vehicle to reach the targeted population at risk safely. The strategy to include calcium in the fortification mix in fortified staple foods seems promising in these countries. However, potential undesired changes on the organoleptic characteristics of fortified foods and products thereof, and operational feasibility at the manufacturing site should be evaluated by the stakeholders during the planning stage. Codex Alimentarius standards should be considered by regulators in order to assure adherence to international standards. While the selected countries already have established national regulations and/or standards for fortification of key staple food vehicles, and there are experiences in the implementation of fortification of some staple foods, national food intake surveys can help plan, design, and modify existing fortification programs as well as monitor food and nutrient consumption to assess risk and benefits.

Zinc Supplementation and Fortification in Mexican Children.

BACKGROUND: Zinc is an essential micronutrient for human health. Approximately 1.4% of deaths worldwide are related to zinc deficiency. In Mexico, 33% of children younger than 5 years are zinc deficient. OBJECTIVE: To give an overview of zinc supplementation and fortification in children younger than 5 years through the analysis of current regulations in Mexico, the availability of these products, and the opinion of Mexican experts in this field. METHODS: We gave an overview of zinc supplementation and fortification strategies in the Mexican pediatric population by conducting a literature review of Mexican studies and national standards concerning zinc supplementation and fortification. Semistructured interviews were conducted with personnel from the main producers of zinc supplements and fortified products and from social assistance programs in Mexico. RESULTS: Zinc supplementation in Mexico has been associated with reduction in the duration and incidence of diarrhea. Through interviews with experts, we identified several barriers in achieving adequate zinc consumption such as problems in social assistance programs that distribute zinc-fortified foods, lack of specific dietary recommendations regarding the intake of zinc, lack of regulation of nonpatented zinc supplements, and inconsistencies in public health actions due to political and administrative changes. CONCLUSION: Despite current regulation and efforts made by social assistance programs, zinc deficiency continues to be a prevalent public health issue. Mexico requires an in-depth analysis of existing barriers and alternatives in order to reduce zinc deficiency.

Sustainable Food Systems and the Mediterranean Diet.

During the past decade, the concept of sustainability has been added to the factors involved in food security. This has led to a more comprehensive and holistic approach to sustainable food systems which considers drivers-environment, geopolitics, demographics, policy regulations, socio-cultural-economic factors, science and technology and infrastructure. The outcomes, similarly, involve many dimensions-environment, food security and nutrition, health and socio-cultural-economic aspects. This article discusses the Mediterranean diet in the context of sustainable food systems and shows (as in all parts of the world) that there is food insecurity in every country as monitored by the Global Nutrition Index. Three recent, major reports published in 2019 suggest what measures need to be taken to improve sustainable food systems. All environmental analyses agree on the need to promote more plant-based diets-achieved practically by using "more forks than knives". The Mediterranean Diet pattern is a case study for a sustainable diet. It has the best scientific evidence for being healthy, together with economic and socio-cultural benefits. A major challenge is that it is not consumed by the majority of the population in the Mediterranean region, and any solution must involve equity-the socially just allocation of resources. The task now is implementation with multi-stakeholder involvement, in the knowledge that "a well fed nation is a healthy nation is a sustainable and productive nation".

Folic acid deficiency declined substantially after introduction of the mandatory fortification programme in Queensland, Australia: a secondary health data analysis.

OBJECTIVE: To investigate the prevalence of folic acid deficiency in Queensland-wide data of routine laboratory measurements, especially in high-risk sub-populations. DESIGN: Secondary health data analysis. SETTING: Analysis of routine folic acid tests conducted by Pathology Queensland (AUSLAB). PARTICIPANTS: Female and male persons aged 0-117 years with routine folic acid testing between 1 January 2004 and 31 December 2015. If repeat tests on the same person were conducted, only the initial test was analysed (n 291 908). RESULTS: Overall the prevalence of folic acid deficiency declined from 7·5 % before (2004-2008) to 1·1 % after mandatory folic acid fortification (2010-2015; P < 0·001) reflecting a relative reduction of 85 %. Levels of erythrocyte folate increased significantly from a median (interquartile range) of 820 (580-1180) nmol/l in 2008 before fortification to 1020 (780-1350) nmol/l in 2010 (P < 0·001) after fortification. The prevalence of folic acid deficiency in the Indigenous population (14 792 samples) declined by 93 % (17·4 v. 1·3 %; P < 0·001); and by 84 % in non-Indigenous residents (7·0 v. 1·1 %; P < 0·001). In a logistic regression model the observed decrease of folic acid deficiency between 2008 and 2010 was found independent of gender, age and ethnicity (ORcrude = 0·20; 95 % CI 0·18, 0·23; P < 0·001; ORadjusted = 0·21; 95 % CI 0·18, 0·23; P < 0·001). CONCLUSIONS: While voluntary folic acid fortification, introduced in 1995, failed especially in high-risk subgroups, the 2009 mandatory folic acid fortification programme coincided with a substantial decrease of folic acid deficiency in the entire population.

Analysing the policy space for the promotion of healthy, sustainable edible oil consumption in India.

OBJECTIVE: To identify opportunities and challenges for the promotion of healthy, sustainable oil consumption in India. DESIGN: We use a framework for policy space analysis which distinguishes between policy context, process and characteristics. SETTING: We focus on the Indian edible oils sector and on factors shaping the policy space at a national level. PARTICIPANTS: The study is based on the analysis of policy documents and semi-structured interviews with key experts and stakeholders in the edible oils sector. RESULTS: We find opportunities associated with the emergence of multisectoral policy frameworks for climate adaptation and non-communicable disease (NCD) prevention at a national level which explicitly include the oils sector, the existence of structures for sectoral policy coordination, some supportive factors for the translation of nutrition evidence into practice, and the possibility of integrating nutrition-sensitive approaches within current state-led agricultural interventions. However, the trade-offs perceived across sustainability, NCD prevention and food security objectives in the vegetable oils sector are considered a barrier for policy influence and implementation. Sustainability and nutrition advocates tend to focus on different segments of the value chain, missing potential synergies. Moreover, policy priorities are dominated by historical concerns for food security, understood as energy provision, as well as economic and strategic priorities. CONCLUSIONS: Systematic efforts towards identifying synergistic approaches, from agricultural production to distribution of edible oils, as well as increased involvement of nutrition advocates with upstream policies in the oils sector, could increase policy influence for advocates of both nutrition and sustainability.

[Cartagena Declaration. The International Declaration on the Right to Nutritional Care and the Fight against Malnutrition]. / Declaración de Cartagena. Declaración Internacional sobre el Derecho al Cuidado Nutricional y la Lucha contra la Malnutrición.

INTRODUCTION: The need to promote the right to nutritional care, to fight against malnutrition and to advance in education and research in clinical nutrition has led all the FELANPE's societies to sign on May 3rd, during the 33rd Congress of the Colombian Clinical Nutrition Association (ACNC) in the city of Cartagena, the International Declaration on the Right to Nutritional Care and the Fight against Malnutrition, "Declaration of Cartagena". The Declaration provides a coherent framework of 13 principles which can serve as a guide for societies, schools and associations affiliated to FELANPE in the development of action plans. In addition, it will serve as an instrument to promote, through governments, the formulation of policies and legislation in the field of clinical nutrition. We believe that the general framework of principles proposed by the Declaration can contribute to raise awareness about the magnitude of this problem and to promote cooperation networks among Latin-American countries. Although this Declaration does not have a binding legal effect, it has an undeniable moral strength and it can provide practical guidance to States. An implementation program will allow developing a toolkit to transform principles into actions.

INTRODUCCIÓN: Frente a la necesidad de promover el derecho al cuidado nutricional, de luchar contra la malnutrición y de avanzar en temas de educación e investigación en nutrición clínica, las sociedades que constituyen la FELANPE firmaron la Declaración Internacional sobre el Derecho al Cuidado Nutricional y la Lucha contra la Malnutrición, "Declaración de Cartagena", el 3 de mayo del presente año en la ciudad de Cartagena, en el marco del 33º Congreso de la Asociación Colombiana de Nutrición Clínica. La Declaración proporciona un marco coherente de 13 principios, los cuales podrán servir de guía a las sociedades afiliadas a la FELANPE en el desarrollo de los planes de acción. Además, servirá como un instrumento para que promuevan, a través de los gobiernos, la formulación de políticas y legislaciones en el campo de la nutrición clínica. Consideramos que el marco general de principios propuesto por la Declaración puede contribuir a crear conciencia acerca de la magnitud de este problema y a forjar redes de cooperación entre los países de la región. Aunque esta Declaración no tiene un efecto jurídico vinculante (obligatorio), tiene una fuerza moral innegable y puede proporcionar orientación práctica a los estados. Un plan de implementación permitirá desarrollar la caja de herramientas necesaria para transformar los principios en acciones.

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.

Strengthening Aboriginal and Torres Strait Islander health policy: lessons from a case study of food and nutrition.

OBJECTIVE: To examine key factors influencing the prioritisation of food and nutrition in Aboriginal and Torres Strait Islander health policy during 1996-2015. DESIGN: A qualitative policy analysis case study was undertaken, combining document analysis with thematic analysis of key informant interviews. SETTING: Australia. PARTICIPANTS: Key actors involved in Aboriginal and Torres Strait Islander health policy between 1996 and 2015 (n 38). RESULTS: Prioritisation of food and nutrition in policy reduced over time. Several factors which may have impeded the prioritisation of nutrition were identified. These included lack of cohesion among the community of nutritionists, Aboriginal and Torres Strait Islander leaders and civil society actors advocating for nutrition; the absence of an institutional home for nutrition policy; and lack of consensus and a compelling policy narrative about how priority nutrition issues should be addressed. Political factors including ideology, dismantling of public health nutrition governance structures and missing the opportunities presented by 'policy windows' were also viewed as barriers to nutrition policy change. Finally, the complexity and multifaceted nature of nutrition as a policy problem and perceived lack of evidence-based solutions may also have constrained its prioritisation in Aboriginal and Torres Strait Islander health policy. CONCLUSIONS: Future advocacy should focus on embedding nutrition within holistic approaches to health and building a collective voice through advocacy coalitions with Aboriginal and Torres Strait Islander leadership. Strategic communication and seizing political opportunities may be as important as evidence for raising the priority of Aboriginal and Torres Strait Islander health issues.

Randomized control trials demonstrate that nutrition-sensitive social protection interventions increase the use of multiple-micronutrient powders and iron supplements in rural pre-school Bangladeshi children.

OBJECTIVE: To examine the impact of a nutrition-sensitive social protection intervention on mothers' knowledge of Fe deficiency, awareness of multiple-micronutrient powders (MMP) and the consumption of MMP and other Fe supplements by their children aged 6-59 months. DESIGN: Two randomized controlled trials with treatment arms including cash transfers, food transfers, cash and food transfers, cash and nutrition behaviour change communication (BCC), and food and nutrition BCC were implemented over two years. Both included a control group that received no transfer or BCC. Transfer recipients were mothers living in poor households with at least one child aged less than 2 years at baseline. Probit models were used to analyse endline data. SETTING: Rural areas in north-west and south Bangladesh. SUBJECTS: Mothers (n 4840) and children 6-59 months (n 4840). RESULTS: A transfer accompanied by nutrition BCC increased the share of mothers with knowledge of Fe deficiency (11·9 and 9·2 percentage points for North and South, respectively, P≤0·01), maternal awareness of MMP (29·0 and 22·2 percentage points, P≤0·01), the likelihood that their children 6-59 months had ever consumed MMP (32 and 11·9 percentage points, P≤0·01), consumed MMP in the preceding week (16·9 and 3·9 percentage points, P≤0·01) and consumed either MMP or an Fe supplement in the preceding week (22·3 and 7·1 percentage points, P≤0·01). Improvements were statistically significant relative to groups that received a transfer only. CONCLUSIONS: Nutrition-sensitive social protection (transfers with BCC added) may be a promising way to advance progress on micronutrient deficiencies.

Trans-Fatty Acids and Cardiovascular Disease: Urgent Need for Legislation.

Hydrogenated oils containing trans-fatty acids (TFA) are used to produce margarine and various processed foods. TFA affect serum lipid levels, fatty acid metabolism, and endothelial function. High TFA intake is linked to increased all-cause mortality, coronary heart disease mortality, and cardiovascular disease (CVD) incidence. Denmark was the first country to introduce a law that limited TFA content in food; this action led to lower CVD mortality. So far 7 European countries have followed this practice, in a few others the food industry voluntarily reduced TFA use. The issue remains mostly unaddressed in the rest of the world. Legal TFA limits should be commonly established as they are the optimal solution considering both CVD prevention and the associated cost savings in public healthcare.

Margarines and Fast-Food French Fries: Low Content of trans Fatty Acids.

The lipid fraction of margarines and fast food French fries, two types of foods traditionally high in trans fatty acids (TFA), is assessed. TFA data reported worldwide during the last 20 years have been gathered and show that some countries still report high TFA amounts in these products. The content of TFA was analysed in margarines (two store and four premium brands) and French-fries from fast-food restaurants (five chains). All samples were collected in Pamplona (Navarra, Spain). The margarines showed mean values of 0.68% and 0.43% (g TFA/100 g fat) for the store and premium brands, respectively. The French fries' values ranged from 0.49% to 0.89%. All samples were lower than the 2% set by some European countries as the maximum legal content of TFA in fats, and contained less than 0.5 g/serving, so they could also be considered "trans free products". This work confirmed that the presence of TFA is not significant in the two analysed products and contributes updated food composition tables, key tools for epidemiological and nutrition studies.

Are Commercial Complementary Food Distributions to Refugees and Migrants in Europe Conforming to International Policies and Guidelines on Infant and Young Child Feeding in Emergencies?

In 2015, more than one million migrants and refugees arrived in Europe. Commercial complementary foods, processed foods marketed for infants and young children 6-23 months of age, were distributed by various humanitarian actors along migrant routes and in European refugee camps. Unsolicited donations and distributions of commercial complementary food products were problematic and divergent from international policies on infant and young child feeding during humanitarian emergencies. Interim guidance regarding commercial complementary foods was published during the peak of the emergency but implemented differently by various humanitarian actors. Clearer and more technical specifications on commercial complementary foods are needed in order to objectively determine their suitability for operational contexts in Europe and emergency nutrition assistance in the future.

Potato Chips, Cookies, and Candy Oh My! Public Commentary on Proposed Rules Regulating Competitive Foods.

BACKGROUND: The Healthy, Hunger-Free Kids Act of 2010 authorizes the U.S. Department of Agriculture (USDA) to establish nutritional standards for all foods sold in schools participating in federally funded meal programs. These foods, known as competitive foods, are commonly found in school cafeterias, vending machines, fundraisers, and snack bars and are associated with unhealthy dietary patterns. However, little is known about the regulatory process and opportunities for public participation to improve school food. AIMS: This study investigates public commentary on the USDA's proposed rules governing competitive foods in schools. METHODS: On February 8, 2013, the USDA's Food and Nutrition Service solicited public comments via Regulations.gov. A corpus of 247,871 public comments was obtained. Duplicate and near-duplicate comments were removed resulting in 3,032 unique comments. Two researchers content analyzed 10% of the sample, removing nonrelevant comments ( n = 249). RESULTS: A majority of commenters are women, and mention their affiliation. Comments tend to be short, and exhibit low levels of complexity. An overwhelming majority of comments expressed concerns about the public health of youth vis-à-vis the new rule, whereas a small but vocal minority opposed the rule for financial and labor reasons and/or opposition to further government regulation. DISCUSSION: Commentary on proposed rules should be specific, avoiding off-topic remarks. Commenters should be strategic, include their credentials, and provide a rationale for their position. CONCLUSION: The rules governing competitive foods are poised to reverse the childhood obesity epidemic, and public commentary may shape these rules.

Reviewing the Nutrition and Health Claims Regulation (EC) No. 1924/2006: What do we know about its challenges and potential impact on innovation?

Health claims potentially represent an opportunity for firms to engage in product differentiation and thereby induce investment into R&D and innovation in the food sector. The Nutrition and Health Claims Regulation (EC) No. 1924/2006 (NHCR) aims at protecting and promoting innovation as one of its objectives. However, existing studies indicate that this regulation may create several challenges for innovation in the food sector. To this end, we review the challenges related to the NHCR (Article 13.1) and its impact on innovation. Extant literature suggests that companies face challenges related to changing list of ingredients, missing transparency, wording of claims, limited financial resources, limited R&D resources, switching product categories and abandoning the functional foods sector. Moreover, current studies imply that so far the NHCR (in specific Article 13.1) does not seem to encourage innovation in the EU food sector.

Exploring the Nutrition and Health Claims Regulation (EC) No. 1924/2006: What is the impact on innovation in the EU food sector?

Literature suggests that despite its positive aim of promoting innovation, the Nutrition and Health Claims Regulation (EC) No. 1924/2006 (NHCR) may bring along several compliance challenges, which might affect innovation in the EU food sector. This study investigates the challenges faced by companies to comply with the NHCR (specifically Article 13.1) and their impact on innovation. To this end, we conducted an online survey with 105 companies involved in the EU food sector. Results indicate that companies perceive wording of claims, missing transparency and limited financial resources as major challenges to comply with the NHCR (Article 13.1). Companies reported not to have increased their R&D expenditure or innovation activities after the NHCR (Article 13.1) was implemented. Thus, this study highlights specific compliance challenges related to the NHCR (Article 13.1) and indicates that currently, the regulation does not seem to have fostered innovation in the EU food sector.