Fortified Foods Are Major Contributors to Apparent Intakes of Vitamin A and Iodine, but Not Iron, in Diets of Women of Reproductive Age in 4 African Countries

Vitamin A fortification: key factors and considerations for effective implementation

Vitamin A fortification plays a crucial role in achieving long-term economic development in developing countries by supporting the growth and development of human capital. While fortification programs involve a range of nutritional, agricultural, economic, and political considerations, there is a lack of a comprehensive overview of the topic in the literature. Our review highlights the importance of holistic approach in designing fortification programs: the effective program should consider (a) the agronomic, economic, and administrative capability of the target regions in regard of fortification method and vehicle to maximize effectiveness; (b) strategies to ensure the producers' and consumers' adoption to enhance uptake rate; and (c) evaluate outcomes with respect to economic metrics rather than focusing solely on before-and-after comparison to avoid biased assessment.

Digital tools and technologies used in food fortification: A scoping review

Food fortification (i.e., industrial fortification and biofortification) increases the micronutrient content of foods to improve population nutrition. Implementing effective fortification programs requires the generation and use of data to inform decision making. The use of digital tools and technologies (DTTs) for such purposes in broader nutrition programs is growing; however, there is limited consolidation of those used in fortification. This scoping review aimed to identify and describe DTTs used in fortification programs. We searched peer-reviewed and gray literature and conducted 17 stakeholder surveys. We then mapped DTTs identified against the fortification and nutrition data value chains. Of 11,741 articles identified, 158 met the inclusion criteria. From the included articles and stakeholder surveys, 125 DTTs were identified across three categories: software and tooling (n = 58), data and information lifecycle (n = 50), and hardware and infrastructure (n = 17). Gaps were identified in processing, post-harvest storage, aggregation, and transport nodes of the fortification value chain, and data prioritization, translation/dissemination, and decision-making nodes of the nutrition data value chain. DTTs have the potential to address challenges faced by fortification stakeholders to generate and use data to improve program decision making and nutritional impact. Further work is needed to standardize terminology, identify relevant DTTs from other sectors, and explore stakeholder needs.

Integrating and coordinating programs for the management of anemia across the life course

Anemia is a major global public health concern with a complex etiology. The main determinants are nutritional factors, infection and inflammation, inherited blood disorders, and women's reproductive biology, but the relative role of each varies between settings. Effective anemia programming, therefore, requires evidence-based, data-driven, contextualized multisectoral strategies, with coordinated implementation. Priority population groups are preschool children, adolescent girls, and pregnant and nonpregnant women of reproductive age. Opportunities for comprehensive anemia programming include: (i) bundling interventions through shared delivery platforms, including antenatal care, community-based platforms, schools, and workplaces; (ii) integrating delivery platforms to extend reach; (iii) integrating anemia and malaria programs in endemic areas; and (iv) integrating anemia programming across the life course. Major barriers to effective anemia programming include weak delivery systems, lack of data or poor use of data, lack of financial and human resources, and poor coordination. Systems strengthening and implementation research approaches are needed to address critical gaps, explore promising platforms, and identify solutions to persistent barriers to high intervention coverage. Immediate priorities are to close the gap between access to service delivery platforms and coverage of anemia interventions, reduce subnational coverage disparities, and improve the collection and use of data to inform anemia strategies and programming.

Micronutrient intake of children in Ghana and Benin: Estimated contribution of diet and nutrition programs

We estimated how micronutrient needs of young children, aged 6-24 months were covered by the standard (traditional) diets in Ghana and Benin, and the contributions of partial breastfeeding and national nutrition programs aimed at improving micronutrient status to overall micronutrient intakes. Estimates of micronutrient intake from standard diets were based on previous surveys, using the food composition table of West Africa (INFOOD). Recommended micronutrient intakes were based on World Health Organization recommendations. Children were grouped in three age groups (6-8, 9-12, and 13-24 months) to capture the changing dynamics of the complementary feeding period. As expected, from 6 months of age onwards, breastmilk didn't cover the micronutrient needs. The standard diets contributed only minimal to micronutrient intakes of children ranging from 0% to 37% of recommended intakes for Ca, Fe, Zn, vitamin A, vitamin D and iodine depending on the micronutrient considered. The contribution of mass (bio)-fortification programs to the coverage of micronutrient needs varied widely, depending on the staple food considered and the country, but overall did not allow to fill the gap in micronutrient needs of children except for vitamin A in some contexts. In contrast, consumption of voluntary fortified complementary food, especially formulated for the needs in this age groups, contributed substantially to overall micronutrient intake and could fill the gap for several micronutrients. The development of young child-targeted programs including micronutrient-dense foods, associated with interventions to increase the diet diversity and meal frequency, could significantly improve micronutrients intakes of children in both Ghana and Benin.

Comparing two simplified questionnaire-based methods with 24-h recalls for estimating fortifiable wheat flour and oil consumption in Mandaluyong City, Philippines

Information on fortifiable food consumption is essential to design, monitor and evaluate fortification programmes, yet detailed methods like 24-h recalls (24HRs) that provide such data are rarely conducted. Simplified questionnaire-based methods exist but their validity compared with 24HRs has not been shown. We compared two simplified methods (i.e., a household food acquisition and purchase questionnaire [FAPQ] and a 7-day semiquantitative food frequency questionnaire [SQ-FFQ]) against 24HRs for estimating fortifiable food consumption. We assessed the consumption of fortifiable wheat flour and oil using a FAPQ and, for wheat flour only, a 7-day SQ-FFQ and compared the results against 24HRs. The participants included children 12-18 months (n = 123) and their mothers 18-49 years selected for a study assessing child vitamin A intake and status in Mandaluyong City, Philippines. For fortifiable wheat flour, the FAPQ estimated considerably lower mean intakes compared to 24HRs for children and mothers (2.2 vs. 14.1 g/day and 5.1 vs. 42.3 g/day, respectively), while the SQ-FFQ estimated slightly higher mean intakes (15.7 vs. 14.1 g/day and 51.5 vs. 42.3 g/day, respectively). For fortifiable oil, the FAPQ estimated considerably higher mean intakes compared to 24HRs for children and mothers (4.6 vs. 1.8 g/day and 12.5 vs. 6.1 g/day, respectively). The SQ-FFQ, but not the FAPQ, generated useful information on fortifiable food consumption that can inform fortification programme design and monitoring decisions in the absence of more detailed individual-level data. Potential adaptations to improve the FAPQ, such as additional questions on foods prepared away from home and usage patterns, merit further research.

Nutritional Status, Dietary Intake and Dietary Diversity of Landfill Waste Pickers

The purpose of this study was to investigate and describe the nutritional status, dietary intake and dietary diversity of waste pickers in South Africa, a socioeconomically vulnerable group who makes a significant contribution to planetary health through salvaging recyclable material from dumpsites. Participants were weighed and measured to calculate body mass index (BMI). Dietary intake was recorded using a standardised multipass 24 h recall. Individual dietary diversity scores were derived from the dietary recall data. Data were collected from nine purposefully selected landfill sites located in six rural towns and three cities in four of the nine provinces in South Africa, providing nutritional status information on 386 participants and dietary intake on 358 participants after data cleaning and coding. The mean BMI of the study sample was 23.22 kg/m². Underweight was more prevalent among males (22.52%) whilst 56.1% of the females were overweight or obese. The average individual dietary diversity score was 2.46, with 50% scoring 2 or less. Dietary intake patterns were characterised as monotonous, starch-based and lacking vegetables and fruits. The nutritional status, dietary intake and dietary diversity of waste pickers reflect their precarious economic status, highlighting the need for health, social and economic policies to improve access and affordability of nutritious food.

Decisions to Start, Strengthen, and Sustain Food Fortification Programs: An Application of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Evidence to Decision (EtD) Framework in Nigeria

Background

Although the potential impact of food fortification to improve the micronutrient status of populations has been demonstrated beyond a doubt, it is constrained in practice by critical gaps in program design and implementation. These are partly linked to suboptimal decision making.

Objectives

We aimed to demonstrate how the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Evidence to Decision (EtD) framework for health system and public health decisions can be applied to formulate recommendations and make decisions in national food fortification programming.

Methods

Following a program impact pathway, we reviewed the literature to define the key decision types and identify the corresponding decision makers necessary for designing and implementing effective food fortification programs. We then applied the GRADE EtD framework to the Nigerian fortification program to illustrate how evidence-informed assessments and conclusions can be made.

Results

Fortification program decisions were classified into 5 types: 1) program initiation; 2) program design; 3) program delivery; 4) program impact; and 5) program continuation. Policymakers, food processors, and (in cases dependent on or considering external funding) development partners are the main decision makers in a fortification program, whereas technical partners play important roles in translating evidence into contextualized recommendations. The availability and certainty of evidence for fortification programs are often low (e.g., quality and coverage data are not routinely collected and there are challenges evaluating impact in such population-based programs using randomized controlled trials) yet decisions must still be made, underscoring the importance of using available evidence. Furthermore, when making program initiation and continuation decisions, coordination with overlapping micronutrient interventions is needed where they coexist.

Conclusions

This framework is a practical tool to strengthen decision-making processes in fortification programs. Using evidence in a systematic and transparent way for decision making can improve fortification program design, delivery, and ultimately health impacts.

The Role of Multiply-Fortified Table Salt and Bouillon in Food Systems Transformation

Our global food system lacks the critically needed micronutrients to meet the daily requirements of the most at-risk populations. Diets also continue to shift toward unhealthy foods, including the increased intake of salt. While most countries exceed the WHO’s recommended levels, sodium does play an essential physiological role. Table salt and other salt-containing condiments, such as bouillon, also have cultural importance, as they are used to enhance the flavor of foods cooked at home. Given their universal consumption across income classes and both urban and rural populations, these condiments are an integral part of the food system and should, therefore, be part of its transformation. Fortification of salt and salt-containing condiments can play a catalytic role in the delivery of population-wide nutritional and health benefits. With relatively consistent levels of intake across the population, these condiments hold high potential for delivering micronutrients beyond iodine while also reducing concerns related to high micronutrient intake, particularly so in countries where the industries are relatively consolidated. As a flexible and complementary strategy to an evolving food system, fortification levels can also be adjusted over time to ensure micronutrient delivery targets continue to be achieved as the system improves, whether through lower intakes of sodium in line with WHO recommendations, enhanced consumption of nutrient-dense foods, and/or broader adoption of biofortified crops. Future areas of innovation are required to realize this vision, including developing affordable salt substitutes to meet cost requirements of consumers in low-and middle-income countries, improving the stability and bioavailability of the micronutrients in condiments so that delivery targets can be reached without affecting sensory attributes, and the development of efficient systems for monitoring population intake and micronutrient status to inform fortification program design and management. Rather than being considered antithetical to the transformation, multiply-fortified salt and bouillon can strengthen our ability to meet the cultural, sensory, nutritional, and health needs of an evolving food system.

Modeling food fortification contributions to micronutrient requirements in Malawi using Household Consumption and Expenditure Surveys

Large-scale food fortification may be a cost-effective intervention to increase micronutrient supplies in the food system when implemented under appropriate conditions, yet it is unclear if current strategies can equitably benefit populations with the greatest micronutrient needs. This study developed a mathematical modeling framework for comparing fortification scenarios across different contexts. It was applied to model the potential contributions of three fortification vehicles (oil, sugar, and wheat flour) toward meeting dietary micronutrient requirements in Malawi through secondary data analyses of a Household Consumption and Expenditure Survey. We estimated fortification vehicle coverage, micronutrient density of the diet, and apparent intake of nonpregnant, nonlactating women for nine different micronutrients, under three food fortification scenarios and stratified by subpopulations across seasons. Oil and sugar had high coverage and apparent consumption that, when combined, were predicted to improve the vitamin A adequacy of the diet. Wheat flour contributed little to estimated dietary micronutrient supplies due to low apparent consumption. Potential contributions of all fortification vehicles were low in rural populations of the lowest socioeconomic position. While the model predicted large-scale food fortification would contribute to reducing vitamin A inadequacies, other interventions are necessary to meet other micronutrient requirements, especially for the rural poor.

The Relationship between Hemoglobin Level and Socio-economic Indicators among Women of Childbearing Age in South Africa: A Secondary Analysis of DHS Data

The nutritional double burden of disease refers to the phenomenon of undernutrition, wasting, stunting, micronutrient deficiency coinciding with overweight, obesity, and diet-related non-communicable diseases, within individuals, households and populations throughout the lifecycle. This study aimed to determine whether there were differences in hemoglobin levels between anthropometric categories and socio-economic factors among women aged 15 to 49 years old in South Africa. Data were obtained from the Demographic and Health Survey (DHS) South Africa survey 2016. There were 2690 women between 15 and 49 years old included in the sample. Variables selected for analysis included height and weight, hemoglobin (adjusted for altitude), wealth index, access to improved water and sanitation. Variables were tested for normality using Q-Q plots. Missing data was removed. Frequencies and percentages were reported for categorical data. Non-parametric continuous variables were reported as medians and interquartile ranges. As data were not normally distributed, analysis was conducted using the Kruskall-Wallis test and Mann-Whitney U test. The type I error rate was set to p < .05. Where it was found that a significant difference exists, post hoc Dunn tests were performed to determine the location of the differences. Anemia was prevalent among 28.9% of the sample and 63.5% were either overweight or obese. Hemoglobin levels were significantly different between normal weight women and women with a body mass index in the obese class I and obese class II respectively (Kruskall-Wallis = 27.014; df = 5; p = .000; n = 2690). There were significant differences in hemoglobin levels between women with access to improved sanitation and those without access (Mann-Whitney U test p = .017), but hemoglobin levels were similar between women with access to improved water and those without (Mann-Whitney U test p = .175). Poorer women had significantly different hemoglobin levels to the wealthiest women in the sample (Kruskall-Wallis = 29.568; df = 4; p = .000). The nutritional double burden of disease is prevalent in South Africa among women of childbearing age. A wealth disparity exists among South African women in terms of hemoglobin levels.

Comparison of Micronutrient Intervention Strategies in Ghana and Benin to Cover Micronutrient Needs: Simulation of Bene-Fits and Risks in Women of Reproductive Age

Overlapping micronutrient interventions might increase the risk of excessive micronutrient intake, with potentially adverse health effects. To evaluate how strategies currently implemented in Benin and Ghana contribute to micronutrient intake in women of reproductive age (WRA), and to assess the risk for excess intakes, scenarios of basic rural and urban diets were built, and different on-going interventions were added. We estimated micronutrient intakes for all different scenarios. Four types of intervention were included in the scenarios: fortification, biofortification, supplementation and use of locally available nutrient-rich foods. Basic diets contributed poorly to daily micronutrient intake in WRA. Fortification of oil and salt were essential to reach daily requirements for vitamin A and iodine, while fortified flour contributed less. Biofortified products could make an important contribution to the coverage of vitamin A needs, while they were not sufficient to cover the needs of WRA. Iron and folic acid supplementation was a major contributor in the intake of iron and folate, but only in pregnant and lactating women. Risk of excess were found for three micronutrients (vitamin A, folic acid and niacin) in specific contexts, with excess only coming from voluntary fortified food, supplementation and the simultaneous overlap of several interventions. Better regulation and control of fortification and targeting of supplementation could avoid excess intakes.

The Potential Contribution of Fortified Maize Flour, Oil, Rice, Salt, and Wheat Flour to Estimated Average Requirements and Tolerable Upper Intake Levels for 15 Nutrients in 153 Countries

Food fortification is designed to improve the nutritional profile of diets. The purpose of this research was to estimate the potential nutrient contribution of fortified maize flour, oil, rice, salt, and wheat flour in 153 countries, using the national intake (or availability) of the food and the nutrient levels required for fortification. This was done under two scenarios—maximum, where 100% of the food is assumed to be industrially processed and fortified, and realistic, where the maximum value is adjusted based on the percent of the food that is industrially processed and fortified. Under the maximum scenario, the median Estimated Average Requirements (EARs) met ranged from 22–75% for 14 nutrients (vitamins A, B1, B2, B3, B6, B12, D, E, folic acid and calcium, fluoride, iron, selenium and zinc), and 338% for iodine. In the realistic scenario, the median EARs met were 181% for iodine and <35% for the other nutrients. In both scenarios, the median Tolerable Upper Intake Levels (ULs) met were <55% for all nutrients. Under the realistic scenario, no country exceeded 100% of the UL for any nutrient. Current fortification practices of the five foods of interest have the global potential to contribute up to 15 nutrients to the diets of people, with minimal risk of exceeding ULs.