Challenges and obstacles implementing evidence-based food fortification policy in a high-income country.

The World Health Organization (WHO) recognizes food fortification as one of the most cost-effective and beneficial public health measures available. Mass fortification policies and regulations can reduce health disparities, including in high-income countries, by improving micronutrient intake among food-insecure or high-risk populations without changing their diet or behavior. While international health organizations have traditionally prioritized technical assistance and grants to medium and low-income countries, it is important to recognize that micronutrient deficiencies may also pose an important yet underappreciated public health problem in many high-income countries. Nevertheless, some high-income countries, including Israel, have been slow to adopt fortification, due to a variety of scientific, technological, regulatory, and political barriers. Overcoming these barriers requires an exchange of knowledge and expertise among the all stakeholders to achieve cooperation and broad public acceptance within countries. Similarly, sharing the experience of countries where the matter is in play may help inform efforts to advance fortification globally. Here we share a perspective on progress and barriers to achieve this goal in Israel, to inform efforts made to avoid the regrettable waste of unrealized human potential from prevalent yet preventable nutrient deficiency conditions, in Israel and beyond.

Correction to: micronutrient deficiency conditions: Global Health issues.

[This corrects the article DOI: 10.1007/BF03391600.].

The key role of government in addressing the pandemic of micronutrient deficiency conditions in Southeast Asia.

Micronutrient deficiency conditions are a major global public health problem. While the private sector has an important role in addressing this problem, the main responsibility lies with national governments, in cooperation with international agencies and donors. Mandatory fortification of basic foods provides a basic necessary intake for the majority and needs to be supported by provision of essential vitamin and mineral supplements for mothers and children and other high risk groups. Fortification by government mandate and regulation is essential with cooperation by private sector food manufacturers, and in the context of broader policies for poverty reduction, education and agricultural reform. Iron, iodine, vitamin A, vitamin B complex, folic acid, zinc, vitamin D and vitamin B12 are prime examples of international fortification experience achieved by proactive governmental nutrition policies. These are essential to achieve the Millennium Development Goals and their follow-up sustainable global health targets. National governmental policies for nutritional security and initiatives are essential to implement both food fortification and targeted supplementation policies to reduce the huge burden of micronutrient deficiency conditions in Southeast Asia and other parts of the world.

The role of schools of public health in capacity building.

Public health has been an enormously effective instrument for improving life expectancy and quality of life. Historically a sphere of governmental activity led by physicians and staffed by sanitarians and nurses, public health has evolved to become a multi-facetted field of societal activity. It engages many agencies and community action in reducing infectious and non-communicable diseases as well as many aspects of lifestyle and health equity. Education for an adequate professional workforce is one of its key functions. Schools of public health have fulfilled this role only partly even in developed countries, but in countries in transition and in low-income countries the problem is much more acute. We discuss the role of mentoring of new schools calling for strong public and private donor support for this as a key issue in global health.

A systematic review of interventions to increase awareness, knowledge, and folic acid consumption before and during pregnancy.

OBJECTIVE: We conducted a systematic review of studies designed to increase awareness of knowledge about, and consumption of folic acid before and during pregnancy. DATA SOURCES: Studies were identified from Cochrane Library, Medline, and the references of primary studies and reviews. STUDY INCLUSION AND EXCLUSION CRITERIA: Studies included randomized controlled trials, quasi-experimental interrupted time series studies, follow-up studies, case-control studies, and before-and-after studies, all of which were conducted between 1992 and 2005 on women ages 15 to 49 years and/or health professionals, evaluating awareness and/or knowledge and/or consumption of folic acid both before and after intervention. Studies were excluded if data were not presented both before and after intervention or were other outcomes than those mentioned here. DATA EXTRACTION: Data were extracted in relation to characteristics of studies, participants, interventions, and outcomes. DATA SYNTHESIS: Because of heterogeneity, we performed a narrative synthesis describing the direction and the size of effects. RESULTS: On average, women's awareness increased from 60% to 72%, knowledge from 21% to 45%, and consumption from 14% to 23%. CONCLUSIONS: Interventions had a positive effect on folic acid intakes before and during pregnancy, although the average usage reached less than 25%.

Addition of essential micronutrients to foods--implication for public health policy in Israel.

Micronutrient deficiencies have reoccupied the center stage of public health policy with the realization that folic acid deficiency results in neural tube defects and possibly other birth defects as well as ischemic heart disease. These, in turn, have raised an older debate on food fortification policy for the elimination of iodine, iron and vitamin D deficiencies. Data from the First Israeli National Health and Nutrition Survey (MABAT 2000) provided an impetus to develop an active national nutrition policy aimed to improve the nutritional status of iodine, iron, vitamins A and D and B-vitamins, including folate. In this paper we examine some of the micronutrient deficiency issues in Israel and their implications for public health, and suggest options for the formulation of policy.

Standardized mortality ratios by region of residence, Israel, 1987-1994: a tool for public health policy.

BACKGROUND: Standardized mortality ratios (SMRs) are used internationally to compare health status across regions and to identify high risk areas for investigation of specific diseases, for funding determination, and for planning purposes. OBJECTIVE: To ascertain regional differences in SMRs by sub-District in Israel for 1987-1994. METHOD: The indirect method of standardization of mortality rates with adjustment for age, gender, and continent of birth was used to calculate SMRs by major cause of death, by sub-District of residence for the Jewish population of Israel. RESULTS: SMRs for all causes of death ranged from regions with low rates (Petah Tikva, Sharon, Rehovot, Ashkelon, and Jerusalem) to those with high rates (Zefat/Golan, Hadera, Yizreel, Ramla, Haifa, Tel Aviv, and Be'er Sheva) (all p<0.0001). Zefat's SMRs are elevated for acute myocardial infarction, stroke, diabetes, and motor vehicle accidents (MVAs). Haifa's SMRs are high for all cardiovascular diseases, liver disease, MVAs, and lung cancer. Be'er Sheva residents had high SMRs for diabetes, liver disease, MVAs, some categories of cardiovascular disease, cervical cancer, and homicide. Yizreel had high SMRs for diabetes, hypertension, stroke, liver disease, and MVAs. Tel Aviv had elevated SMRs for septicemia, acute MI, perinatal causes, and colon, lung and breast cancer. Jerusalem (p<0.0001) and Kinneret residents (p<0.05) had low SMRs for everything except congenital anomalies. CONCLUSIONS: Regional SMR differences, adjusted for age, gender, and ethnicity, may be due to socioeconomic, nutritional, environmental, occupational, or health care factors. SMRs provide a tool to identify regions for epidemiological investigation and priorities for preventive interventions. Regional health monitoring should be undertaken routinely on mortality data, as well as other national databases, as part of national health monitoring.

Developing schools of public health in countries of Eastern Europe and the Commonwealth of Independent States.

Countries of Eastern Europe and the Commonwealth of Independent States are facing a combination of difficulties in health including high rates of mortality from preventable diseases, and pressures for reform of their health care systems. The development of schools of public health is an important priority for international aid and for national government attention. This provides a challenge of integrating experience from many countries in the industrialized world and academic centers of excellence in the field of public health. Traditional departments of social hygiene within medical academies need to evolve to educate new generations of doctors to cope with challenges facing the health systems in these countries. Development of post-graduate centers of training will also be needed as independent schools of public health within single or multi-faculty universities to train health workers in a New Public Health. This paper outlines the mission of a school of public health (SPH), and the steps needed to achieve its objectives, with examples of several schools at relatively advanced and moderate levels of development. The purpose is to provide guidelines for those SPHs under development that are seeking international support and resources.