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Mineral micronutrient status and spatial distribution among the Ethiopian population. Br J Nutr 2022; 128:2170-2180. [PMID: 35109956 PMCID: PMC9661372 DOI: 10.1017/s0007114522000319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Multiple micronutrient deficiencies are widespread in Ethiopia. However, the distribution of Se and Zn deficiency risks has previously shown evidence of spatially dependent variability, warranting the need to explore this aspect for wider micronutrients. Here, blood serum concentrations for Ca, Mg, Co, Cu and Mo were measured (n 3102) on samples from the Ethiopian National Micronutrient Survey. Geostatistical modelling was used to test spatial variation of these micronutrients for women of reproductive age, who represent the largest demographic group surveyed (n 1290). Median serum concentrations were 8·6 mg dl-1 for Ca, 1·9 mg dl-1 for Mg, 0·4 µg l-1 for Co, 98·8 µg dl-1 for Cu and 0·2 µg dl-1 for Mo. The prevalence of Ca, Mg and Co deficiency was 41·6 %, 29·2 % and 15·9 %, respectively; Cu and Mo deficiency prevalence was 7·6 % and 0·3 %, respectively. A higher prevalence of Ca, Cu and Mo deficiency was observed in north western, Co deficiency in central and Mg deficiency in north eastern parts of Ethiopia. Serum Ca, Mg and Mo concentrations show spatial dependencies up to 140-500 km; however, there was no evidence of spatial correlations for serum Co and Cu concentrations. These new data indicate the scale of multiple mineral micronutrient deficiency in Ethiopia and the geographical differences in the prevalence of deficiencies suggesting the need to consider targeted responses during the planning of nutrition intervention programmes.
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Estimates of Dietary Mineral Micronutrient Supply from Staple Cereals in Ethiopia at a District Level. Nutrients 2022; 14:nu14173469. [PMID: 36079728 PMCID: PMC9459787 DOI: 10.3390/nu14173469] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 08/18/2022] [Accepted: 08/19/2022] [Indexed: 11/20/2022] Open
Abstract
Recent surveys have revealed substantial spatial variation in the micronutrient composition of cereals in Ethiopia, where a single national micronutrient concentration values for cereal grains are of limited use for estimating typical micronutrient intakes. We estimated the district-level dietary mineral supply of staple cereals, combining district-level cereal production and crop mineral composition data, assuming cereal consumption of 300 g capita−1 day−1 proportional to district-level production quantity of each cereal. We considered Barley (Hordeum vulgare L.), maize (Zea mays L.), sorghum (Sorghum bicolor (L.) Moench), teff (Eragrostis tef (Zuccagni) Trotter), and wheat (Triticum aestivum L.) consumption representing 93.5% of the total cereal production in the three major agrarian regions. On average, grain cereals can supply 146, 23, and 7.1 mg capita−1 day−1 of Ca, Fe, and Zn, respectively. In addition, the Se supply was 25 µg capita−1 day−1. Even at district-level, cereals differ by their mineral composition, causing a wide range of variation in their contribution to the daily dietary requirements, i.e., for an adult woman: 1–48% of Ca, 34–724% of Fe, 17–191% of Se, and 48–95% of Zn. There was considerable variability in the dietary supply of Ca, Fe, Se, and Zn from staple cereals between districts in Ethiopia.
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Meazaw MW, Chojenta C, Forder P, Taddele T, Loxton D. Health Care Readiness in Management of Preeclampsia/Eclampsia in Ethiopia: Evidence from National Facility-Based Survey. Healthc Policy 2022; 15:1225-1241. [PMID: 35734013 PMCID: PMC9208466 DOI: 10.2147/rmhp.s366055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 06/05/2022] [Indexed: 11/23/2022] Open
Abstract
Background Early case detection, treatment, and timely referral for better services can significantly reduce the negative outcomes of preeclampsia and eclampsia. However, evidence on health facilities' readiness to provide such services and the associated challenges is limited in Ethiopia. Therefore, this study aimed to assess the readiness of Ethiopian health care facilities to manage preeclampsia and eclampsia. Methods This study used the 2016 Ethiopia national emergency management of obstetrics and newborn care (EmONC) survey. This survey was a national cross-sectional census of health facilities that provided delivery services. Data on facility infrastructure, equipment and supplies were collected through a facility checklist, and interview health provider experiences. Cross tabulation, summarisation and chi square tests by facility type, location, and management authority were conducted. Results There were 3804 health facilities included in the survey across all regions of Ethiopia. The majority of facilities (92%) were public/government managed with only 1% of available hospitals located in rural areas. Poor availability of dipsticks for proteinuria tests (55.3%), caesarean sections (7.9%), and ambulance services (18.4%) were reported across health facilities with high variations in terms of facility type, location, and type of managing authority. Diazepam was a widely available anticonvulsant compared with magnesium sulfate (MgSO4), with more available in private for-profit facilities compared with public facilities. Nearly one third of health care providers were not trained to administer MgSO4 intravenously. The result indicated that the chi-square test was statistically significant at P < 0.001. Conclusions and Recommendations There were notable gaps in readiness of facilities in detection and management of preeclampsia/eclampsia that increase maternal and perinatal mortality in Ethiopia. Therefore, availability of essential supplies, medications, and referrals are required. In addition, refresher training to healthcare providers on screening, diagnosis and management of preeclampsia/eclampsia and continuous supervision should be provided.
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Affiliation(s)
- Maereg Wagnaw Meazaw
- Federal Ministry of Health, Addis Ababa, Ethiopia.,Centre for Women's Health Research, School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Newcastle, NSW, Australia
| | - Catherine Chojenta
- Centre for Women's Health Research, School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Newcastle, NSW, Australia
| | - Peta Forder
- Centre for Women's Health Research, School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Newcastle, NSW, Australia
| | - Tefera Taddele
- Health System and Reproductive Health Directorate, The Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Deborah Loxton
- Centre for Women's Health Research, School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Newcastle, NSW, Australia
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Tefera N, Mulualem D, Baye K, Tessema M, Woldeyohannes M, Yehualashet A, Whiting SJ. Association Between Dietary Fluoride and Calcium Intake of School-Age Children With Symptoms of Dental and Skeletal Fluorosis in Halaba, Southern Ethiopia. FRONTIERS IN ORAL HEALTH 2022; 3:853719. [PMID: 35309280 PMCID: PMC8931494 DOI: 10.3389/froh.2022.853719] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 02/09/2022] [Indexed: 11/18/2022] Open
Abstract
Background In the Ethiopian Rift Valley, ways to reduce the fluoride (F) burden from drinking water have been unsuccessful. Calcium (Ca) intake may mitigate fluorosis by binding with F ions and preventing absorption. The purpose of this study was to examine the association between Ca intake and proportion of fluorosis symptoms in school-age children in an area where F levels are known to be higher than WHO limit of 1.5 mg F/L water. Methods A cross-sectional survey in the Halaba zone involved 135 eligible children aged 6–13 year who were recruited to have dental fluorosis assessed by a dentist and skeletal fluorosis assessed by a physiotherapist. Dietary Ca intake was determined by 24-h recall. Food items and samples from ground wells, taps and spring water were collected for F concentration. Associations were measured using bivariate logistic regression, adjusted for known confounders. Results Water F averaged 5.09 mg/L. Total F intake was high, 10.57 mg/day, and Ca intake was low, 520 mg/day. Prevalence of dental fluorosis (from very mild to severe symptoms) was 73.1% for younger children (6–8 years) and 68.3 % for older children (9–13 years). The prevalence of children having symptoms of skeletal fluorosis ranged between 55.1 and 72.4%, with no apparent age difference. Dietary F intake of children was significantly positively associated with presence of dental fluorosis. Dietary Ca intake of children was significantly negatively associated with dental fluorosis. Higher than average dietary F intake significantly increased the odds of developing skeletal fluorosis symptoms when measured as inability to stretch and fold arms to touch back of head. Higher than average Ca intake was significantly associated with decreased odds of developing skeletal fluorosis measured as inability to bend body to touch the toes or floor. Conclusions High dietary F, as expected, was associated with fluorosis in children. In the presence of higher Ca intake (>520 mg/day) some fluorosis symptoms were mitigated. There is a need to improve Ca intakes as all were below recommended levels, and this nutritional strategy may also reduce burden of excess F.
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Affiliation(s)
- Nahom Tefera
- Ethiopia and Food Science and Nutrition Research Directorate Ethiopian Public Health Institute, Center for Food Science and Nutrition, College of Natural and Computational Sciences Addis Ababa University, Addis Ababa, Ethiopia
- *Correspondence: Nahom Tefera
| | - Demmelash Mulualem
- School of Human Nutrition and Food Science, Hawassa University, Awasa, Ethiopia
| | - Kaleab Baye
- Center for Food Science and Nutrition, College of Natural and Computational Sciences Addis Ababa University, Addis Ababa, Ethiopia
| | - Masresha Tessema
- Food Science and Nutrition Research Directorate Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Meseret Woldeyohannes
- Food Science and Nutrition Research Directorate Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Asrat Yehualashet
- Food Science and Nutrition Research Directorate Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Susan J. Whiting
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK, Canada
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Mulualem D, Hailu D, Tessema M, Whiting SJ. Association of Dietary Calcium Intake with Dental, Skeletal and Non-Skeletal Fluorosis among Women in the Ethiopian Rift Valley. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19042119. [PMID: 35206307 PMCID: PMC8871530 DOI: 10.3390/ijerph19042119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/31/2022] [Accepted: 02/08/2022] [Indexed: 11/16/2022]
Abstract
Fluorosis is a major public health problem in the Rift Valley of Ethiopia. Low calcium (Ca) intake may worsen fluorosis symptoms. We assessed the occurrence of fluorosis symptoms among women living in high-fluoride (F) communities in South Ethiopia and their associations with dietary Ca intake. Women (n = 270) from two villages provided clinical and questionnaire data. Dental fluorosis examination was done using Dean’s Index, and skeletal and non-skeletal fluorosis assessment was carried out using physical tests and clinical symptoms. Daily Ca intake was estimated by a food frequency questionnaire. Food, drinking water and beverage samples were analyzed for F level. Many subjects (56.3%) exhibited dental fluorosis. One-third of the women were unable to perform the physical exercises indicative of skeletal fluorosis; about half had ≥2 symptoms of skeletal/non-skeletal fluorosis. The average F level in drinking water sources was ~5 mg/L. The F content in staple food samples varied from 0.8–13.6 mg/kg. Average Ca intake was 406 ± 97 mg/day. Women having ≤400 mg/day Ca intake had ~3 times greater odds of developing skeletal rigidity with joint pains [AOR = 2.8, 95%CI: 1.6, 5.0] and muscular weakness [AOR = 2.9, 95%CI: 1.3, 6.3] compared to those with higher intakes. No association of calcium intake was seen with dental fluorosis. As low dietary Ca intake was associated with symptoms related to skeletal and non-skeletal fluorosis, this warrants nutritional intervention on calcium intakes in this setting.
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Affiliation(s)
- Demmelash Mulualem
- School of Human Nutrition and Food Science, Hawassa University, Hawassa P.O. Box 5, Ethiopia;
| | - Dejene Hailu
- School of Public Health, Hawassa University, Hawassa P.O. Box 5, Ethiopia;
| | | | - Susan Joyce Whiting
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK S7N 5E5, Canada
- Correspondence:
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Bourassa MW, Abrams SA, Belizán JM, Boy E, Cormick G, Quijano CD, Gibson S, Gomes F, Hofmeyr GJ, Humphrey J, Kraemer K, Lividini K, Neufeld LM, Palacios C, Shlisky J, Thankachan P, Villalpando S, Weaver CM. Interventions to improve calcium intake through foods in populations with low intake. Ann N Y Acad Sci 2022; 1511:40-58. [PMID: 35103316 PMCID: PMC9306636 DOI: 10.1111/nyas.14743] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 11/15/2021] [Accepted: 12/05/2021] [Indexed: 11/28/2022]
Abstract
Calcium intake remains inadequate in many low- and middle-income countries, especially in Africa and South Asia, where average intakes can be below 400 mg/day. Given the vital role of calcium in bone health, metabolism, and cell signaling, countries with low calcium intake may want to consider food-based approaches to improve calcium consumption and bioavailability within their population. This is especially true for those with low calcium intake who would benefit the most, including pregnant women (by reducing the risk of preeclampsia) and children (by reducing calcium-deficiency rickets). Specifically, some animal-source foods that are naturally high in bioavailable calcium and plant foods that can contribute to calcium intake could be promoted either through policies or educational materials. Some food processing techniques can improve the calcium content in food or increase calcium bioavailability. Staple-food fortification with calcium can also be a cost-effective method to increase intake with minimal behavior change required. Lastly, biofortification is currently being investigated to improve calcium content, either through genetic screening and breeding of high-calcium varieties or through the application of calcium-rich fertilizers. These mechanisms can be used alone or in combination based on the local context to improve calcium intake within a population.
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Affiliation(s)
| | | | - José M Belizán
- Centro de Investigaciones en Epidemiología y Salud Pública (CIESP), Instituto de Efectividad Clínica y Sanitaria (IECS-CONICET), Buenos Aires, Argentina
| | | | - Gabriela Cormick
- Centro de Investigaciones en Epidemiología y Salud Pública (CIESP), Instituto de Efectividad Clínica y Sanitaria (IECS-CONICET), Buenos Aires, Argentina.,Departamento de Salud, Universidad Nacional de La Matanza UNLAM, San Justo, Argentina
| | | | - Sarah Gibson
- Children's Investment Fund Foundation, London, UK
| | - Filomena Gomes
- New York Academy of Sciences, New York, New York.,NOVA Medical School, Universidade NOVA de Lisboa, Lisboa, Portugal
| | - G Justus Hofmeyr
- University of Botswana, Gaborone, Botswana.,University of the Witwatersrand and Walter Sisulu University, Mthatha, South Africa
| | - Jean Humphrey
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Klaus Kraemer
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Sight and Life Foundation, Basel, Switzerland
| | | | | | | | | | | | | | - Connie M Weaver
- Purdue University, West Lafayette, Indiana.,San Diego State University, San Diego, California
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Efficacy of Calcium-Containing Eggshell Powder Supplementation on Urinary Fluoride and Fluorosis Symptoms in Women in the Ethiopian Rift Valley. Nutrients 2021; 13:nu13041052. [PMID: 33804976 PMCID: PMC8063921 DOI: 10.3390/nu13041052] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/09/2021] [Accepted: 03/21/2021] [Indexed: 12/12/2022] Open
Abstract
Dietary calcium binds Fluoride (F), thus preventing excess F absorption. We aimed to assess the efficacy of supplementing calcium-containing Eggshell Powder (ESP) on F absorption using urine F excretion and on fluorosis symptoms. In total, 82 women (41 Intervention Group, IG; 41 Control Group, CG) were recruited; overall, 39 in each group completed the trial. Morning spot urine was collected before (baseline, BL) and after (endline, EL) the intervention that was 6-months daily supplementation with 2.4 g ESP (providing ~1000 mg of calcium). Dental, skeletal, and non-skeletal fluorosis assessments was carried out at BL and, except for dental, at EL. Relative risk (RR) and linear generalized estimating equation were used to compare outcomes between groups. At BL, urinary F excretion in the IG and CG groups was similar, ~10 mg/L. At EL, urinary F excretion in IG women was six-fold lower (β = -6.1 (95% CI: -7.1, -5.1)) compared to CG. The risk of developing skeletal and non-skeletal fluorosis were significantly (p < 0.001) reduced in the intervention group. A significant reduction in urinary F excretion and reduction in many fluorosis symptoms were observed among women supplemented with calcium-containing ESP, thus providing evidence for using this dietary calcium source for mitigation of fluorosis. Clinical trials registration: NCT03355222.
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Klemm GC, Birhanu Z, Ortolano SE, Kebede Y, Martin SL, Mamo G, Dickin KL. Integrating Calcium Into Antenatal Iron-Folic Acid Supplementation in Ethiopia: Women's Experiences, Perceptions of Acceptability, and Strategies to Support Calcium Supplement Adherence. GLOBAL HEALTH: SCIENCE AND PRACTICE 2020; 8:413-430. [PMID: 33008855 PMCID: PMC7541115 DOI: 10.9745/ghsp-d-20-00008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 06/16/2020] [Indexed: 01/10/2023]
Abstract
Recommendations for antenatal calcium supplementation to prevent preeclampsia could substantially reduce maternal mortality, but adherence to multiple daily doses may constrain effectiveness. World Health Organization guidelines recommend 3 daily calcium supplements (1.5-2 g/d), taken separately from 1 iron-folic acid (IFA) supplement; however, limited data suggest lower calcium doses may also be effective. We conducted mixed-methods household trials to identify strategies for supporting adherence and integrating calcium into antenatal IFA supplementation programming in Ethiopia. Participants were randomly assigned to 3 regimens varying in dose and timing and were later given a choice of regimens. Semistructured interviews conducted over 6 weeks explored acceptability, barriers, and facilitators and offered opportunities to choose calcium pill type. Interviews were transcribed, translated, and analyzed thematically. Calcium adherence was measured using medication event monitoring. All participants (N=48) agreed to try supplementation. Adherence barriers included forgetting to take pills when busy or travelling and perceived side effects. Midday doses were the most challenging because of farming, market, and social events; women avoided taking supplements in public due to fear of being perceived as HIV positive. Social support from families, visual reminders, and anticipated benefits motivated adherence. More participants (75%) selected chewable versus conventional supplements due to organoleptic properties, but this preference declined over time. Adherence rates did not substantially differ across regimens with 2 (81.1%), 3 (83.4%), or 4 (77.1%) pill-taking events. Women indicated that the 2-event regimen was more acceptable than 3- and 4-event regimens, but this acceptability was not associated with higher adherence. Consequently, mean daily calcium consumption (811.3 mg) was lower than for 3-event (1,251.1 mg) and 4-event (1,156.4 mg) regimens. Integrating calcium into antenatal IFA supplementation is acceptable to Ethiopian women, with a 3-event regimen yielding the highest consumption rates. Despite women experiencing challenges with midday dosing and stigma, using simple home-based strategies and being counseled on the purpose of supplementation were more effective than reducing dosage for mitigating barriers and improving adherence.
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Affiliation(s)
- Gina C Klemm
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Zewdie Birhanu
- Faculty of Public Health, Department of Health, Behavior and Society, Jimma University, Jimma, Ethiopia
| | - Stephanie E Ortolano
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Yohannes Kebede
- Faculty of Public Health, Department of Health, Behavior and Society, Jimma University, Jimma, Ethiopia
| | - Stephanie L Martin
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Girma Mamo
- Ethiopia-Canada Cooperation Office, Nutrition International, Addis Ababa, Ethiopia
| | - Katherine L Dickin
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA.
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Cormick G, Betrán AP, Metz F, Palacios C, Beltrán-Velazquez F, García-Casal MDLN, Peña-Rosas JP, Hofmeyr GJ, Belizán JM. Regulatory and Policy-Related Aspects of Calcium Fortification of Foods. Implications for Implementing National Strategies of Calcium Fortification. Nutrients 2020; 12:nu12041022. [PMID: 32276435 PMCID: PMC7230677 DOI: 10.3390/nu12041022] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 03/18/2020] [Accepted: 03/26/2020] [Indexed: 02/08/2023] Open
Abstract
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. 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.
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Affiliation(s)
- Gabriela Cormick
- Department of Mother and Child Health Research, Institute for Clinical Effectiveness and Health Policy (IECS-CONICET), Ciudad de Buenos Aires 1414, Argentina;
- Departamento de Salud, Universidad Nacional de La Matanza (UNLAM), San Justo 1903, Argentina
- Correspondence: ; Tel.: +54-114-7778-767
| | - Ana Pilar Betrán
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, 1211 Geneva 27, Switzerland;
| | - Fletcher Metz
- Department of Biology, Carleton College, Northfield, MN 55057, USA;
| | - Cristina Palacios
- Department of Dietetics and Nutrition, Stempel School of Public Health, Florida International University; Miami, FL 33199, USA;
| | - Filiberto Beltrán-Velazquez
- Department of Nutrition and Food Safety, World Health Organization, 1211 Geneva 27, Switzerland; (F.B.-V.); (M.d.l.N.G.-C.); (J.P.P.-R.)
| | - María de las Nieves García-Casal
- Department of Nutrition and Food Safety, World Health Organization, 1211 Geneva 27, Switzerland; (F.B.-V.); (M.d.l.N.G.-C.); (J.P.P.-R.)
| | - Juan Pablo Peña-Rosas
- Department of Nutrition and Food Safety, World Health Organization, 1211 Geneva 27, Switzerland; (F.B.-V.); (M.d.l.N.G.-C.); (J.P.P.-R.)
| | - G. Justus Hofmeyr
- Effective Care Research Unit, Eastern Cape Department of Health, Universities of the Witwatersrand and Fort Hare, East London 5200, South Africa;
- Obstetrics and Gynaecology Department, University of Botswana, Private Bag UB 0022, Gaborone, Botswana
| | - José M. Belizán
- Department of Mother and Child Health Research, Institute for Clinical Effectiveness and Health Policy (IECS-CONICET), Ciudad de Buenos Aires 1414, Argentina;
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