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Rodas-Moya S, Giudici FM, Owolabi A, Samuel F, Kodish SR, Lachat C, Abreu TC, van het Hof KH, Osendarp SJM, Brouwer ID, Feskens EJM, Melse-Boonstra A. A generic theory of change-based framework with core indicators for monitoring the effectiveness of large-scale food fortification programs in low- and middle-income countries. Front Nutr 2023; 10:1163273. [PMID: 37426192 PMCID: PMC10324612 DOI: 10.3389/fnut.2023.1163273] [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] [Received: 02/10/2023] [Accepted: 05/17/2023] [Indexed: 07/11/2023] Open
Abstract
Large-scale food fortification (LSFF) programs are widely implemented in low- and middle-income countries (LMIC) to alleviate micronutrient deficiencies. However, these programs may not achieve the desired impact due to poor design or bottlenecks in program implementation. Monitoring and evaluation (M&E) frameworks and a set of agreed indicators can help to benchmark progress and to strengthen the evidence-base of effectiveness in a standardized way. We aimed to formulate recommendations towards core indicators for evaluating the effectiveness of LSFF programs with their associated metrics, methods, and tools (IMMT). For this, we used a multi-method iterative approach, including a mapping review of the literature, semi-structured interviews with international experts, compilation of a generic Theory of Change (ToC) framework for LSFF program delivery, and selection of IMMT for M&E of LSFF programs at key stages along the ToC delivery framework. Lastly, we conducted exploratory, qualitative interviews with key informants in Nigeria to explore experiences and perceptions related to the implementation of LSFF programs in Nigeria's context, and their opinion towards the proposed set of core IMMT. The literature search resulted in 14 published and 15 grey literature documents, from which we extracted a total of 41 indicators. Based on the available literature and interviews with international experts, we mapped a ToC delivery framework and selected nine core indicators at the output, outcome and impact level for M&E of the effectiveness of LSFF programs. Key informants in Nigeria revealed that the main bottlenecks for implementation of the proposed IMMT are related to the lack of technical capacity, equipment, laboratory infrastructure, and financial resources. In conclusion, we propose a set of nine core indicators for enabling comprehensive M&E of the effectiveness of LSFF programs in LMIC. This proposed set of core indicators can be used for further evaluation, harmonization and integration in national and international protocols for M&E of LSFF programs.
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Affiliation(s)
- Santiago Rodas-Moya
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
| | - Francesca M. Giudici
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
| | - Adedotun Owolabi
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
| | - Folake Samuel
- Department of Human Nutrition and Dietetics, College of Medicine, Faculty of Public Health, University of Ibadan, Ibadan, Oyo State, Nigeria
| | - Stephen R. Kodish
- Department of Nutritional Sciences and Biobehavioral Health, Pennsylvania State University, University Park, PA, United States
| | - Carl Lachat
- Department of Food Technology, Safety and Health, Faculty of Bioscience Engineering, Ghent University, Ghent, Belgium
| | - Taymara C. Abreu
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
- Department of Epidemiology and Data Science, Amsterdam UMC, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Karin H. van het Hof
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
| | - Saskia J. M. Osendarp
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
- The Micronutrient Forum, Washington, DC, United States
| | - Inge D. Brouwer
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
| | - Edith J. M. Feskens
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
| | - Alida Melse-Boonstra
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
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Endevelt R, Tulchinsky TH, Stahl Z, Mor Z, Davidovitch N, Levine H, Troen AM. Challenges and obstacles implementing evidence-based food fortification policy in a high-income country. Front Public Health 2023; 11:1052314. [PMID: 37006576 PMCID: PMC10061091 DOI: 10.3389/fpubh.2023.1052314] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 02/20/2023] [Indexed: 03/18/2023] Open
Abstract
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.
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Affiliation(s)
- Ronit Endevelt
- The Israel Ministry of Health, Jerusalem, Israel
- School of Public Health, Faculty of Welfare and Health Sciences, Haifa University, Haifa, Israel
| | | | - Ziva Stahl
- The Israel Ministry of Health, Jerusalem, Israel
- Department of Public Health, Ashkelon Academic College, Ashkelon, Israel
- Department of Health Systems Management, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Zohar Mor
- The Israel Ministry of Health, Jerusalem, Israel
- Department of Public Health, Ashkelon Academic College, Ashkelon, Israel
| | - Nadav Davidovitch
- Department of Health Systems Management, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Hagai Levine
- The Hebrew University–Hadassah Medical Center Braun School of Public Health & Community Medicine, The Hebrew University of Jerusalem Faculty of Medicine, Jerusalem, Israel
| | - Aron M. Troen
- The School of Nutritional Sciences and Institute of Biochemistry Food and Nutrition Science, The Robert H. Smith Faculty of Agriculture Food and Environment, The Hebrew University of Jerusalem, Jerusalem, Israel
- *Correspondence: Aron M. Troen
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Whitfield KC, Smith TJ, Rohner F, Wieringa FT, Green TJ. Thiamine fortification strategies in low- and middle-income settings: a review. Ann N Y Acad Sci 2021; 1498:29-45. [PMID: 33496051 PMCID: PMC8451796 DOI: 10.1111/nyas.14565] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 12/30/2020] [Accepted: 01/09/2021] [Indexed: 12/13/2022]
Abstract
Thiamine (vitamin B1 ) is an essential micronutrient in energy metabolism and cognitive and neurological health. Thiamine deficiency disorders (TDDs) have a range of clinical presentations that result in various morbidities and can be fatal if not promptly recognized and treated, especially in infants. To intervene, thiamine intakes by breastfeeding mothers and others at risk of thiamine deficiency should be increased to ensure adequate thiamine intake. Although thiamine fortification programs have a long history in high-income countries, there are few mandatory fortification programs to address TDDs in low- and middle-income countries (LMICs), particularly in the regions of greatest concern, South and Southeast Asia. This review highlights essential aspects for consideration in the development of a mandatory fortification program in LMICs, including an overview of the data required to model fortification dosing schemes, available thiamine fortificants, and potential fortification vehicles, as well as identifies current knowledge gaps.
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Affiliation(s)
- Kyly C. Whitfield
- Department of Applied Human NutritionMount Saint Vincent UniversityHalifaxNova ScotiaCanada
| | - Taryn J. Smith
- Institute for Global NutritionUniversity of California DavisDavisCalifornia
| | | | - Frank T. Wieringa
- UMR‐95 QualiSud, French National Research Institute for Sustainable Development (IRD)CIRAD/IRD/University of Montpellier/SupAgro/University of Avignon/University of RéunionAvignonFrance
| | - Tim J. Green
- SAHMRI Women and KidsSouth Australian Health and Medical Research InstituteAdelaideSouth AustraliaAustralia
- School of MedicineUniversity of AdelaideAdelaideSouth AustraliaAustralia
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Bhavya SN, Prakash J. Nutritional properties of iron fortified flatbreads enriched with greens and legumes. J FOOD PROCESS PRES 2021. [DOI: 10.1111/jfpp.15495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | - Jamuna Prakash
- Department of Food Science and Nutrition University of Mysore Mysuru India
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Oghbaei M, Prakash J. Effect of dehulling and cooking on nutritional quality of chickpea (Cicer arietinum L.) germinated in mineral fortified soak water. J Food Compost Anal 2020. [DOI: 10.1016/j.jfca.2020.103619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Mkambula P, Mbuya MNN, Rowe LA, Sablah M, Friesen VM, Chadha M, Osei AK, Ringholz C, Vasta FC, Gorstein J. The Unfinished Agenda for Food Fortification in Low- and Middle-Income Countries: Quantifying Progress, Gaps and Potential Opportunities. Nutrients 2020; 12:nu12020354. [PMID: 32013129 PMCID: PMC7071326 DOI: 10.3390/nu12020354] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 01/23/2020] [Accepted: 01/27/2020] [Indexed: 12/18/2022] Open
Abstract
Large-scale food fortification (LSFF) is a cost-effective intervention that is widely implemented, but there is scope to further increase its potential. To identify gaps and opportunities, we first accessed the Global Fortification Data Exchange (GFDx) to identify countries that could benefit from new fortification programs. Second, we aggregated Fortification Assessment Coverage Toolkit (FACT) survey data from 16 countries to ascertain LSFF coverage and gaps therein. Third, we extended our narrative review to assess current innovations. We identified 84 countries as good candidates for new LSFF programs. FACT data revealed that the potential of oil/ghee and salt fortification is not being met due mainly to low coverage of adequately fortified foods (quality). Wheat, rice and maize flour fortification have similar quality issues combined with lower coverage of the fortifiable food at population-level (<50%). A four-pronged strategy is needed to meet the unfinished agenda: first, establish new LSFF programs where warranted; second, systems innovations informed by implementation research to address coverage and quality gaps; third, advocacy to form new partnerships and resources, particularly with the private sector; and finally, exploration of new fortificants and vehicles (e.g. bouillon cubes; salt fortified with multiple nutrients) and other innovations that can address existing challenges.
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Affiliation(s)
- Penjani Mkambula
- Global Alliance for Improved Nutrition, Rue de Varembé 7, 1202 Geneva, Switzerland; (V.M.F.); (F.C.V.)
- Correspondence: (P.M.);
| | - Mduduzi N. N. Mbuya
- Global Alliance for Improved Nutrition, Rue de Varembé 7, 1202 Geneva, Switzerland; (V.M.F.); (F.C.V.)
- Correspondence: (P.M.);
| | - Laura A. Rowe
- Food Fortification Initiative, 1518 Clifton Road, Atlanta, GA 30322, USA;
| | | | - Valerie M. Friesen
- Global Alliance for Improved Nutrition, Rue de Varembé 7, 1202 Geneva, Switzerland; (V.M.F.); (F.C.V.)
| | - Manpreet Chadha
- Nutrition International 180 Elgin St., Suite 1000, Ottawa, ON K2P 2K3, Canada;
| | - Akoto K. Osei
- Helen Keller International, Regional Office for Africa, Dakar BP 29.898, Senegal;
| | - Corinne Ringholz
- World Food Programme, Via Cesare Giulio Viola, 68, 00148 Rome, Italy;
| | - Florencia C. Vasta
- Global Alliance for Improved Nutrition, Rue de Varembé 7, 1202 Geneva, Switzerland; (V.M.F.); (F.C.V.)
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Roth DE, Abrams SA, Aloia J, Bergeron G, Bourassa MW, Brown KH, Calvo MS, Cashman KD, Combs G, De-Regil LM, Jefferds ME, Jones KS, Kapner H, Martineau AR, Neufeld LM, Schleicher RL, Thacher TD, Whiting SJ. Global prevalence and disease burden of vitamin D deficiency: a roadmap for action in low- and middle-income countries. Ann N Y Acad Sci 2018; 1430:44-79. [PMID: 30225965 DOI: 10.1111/nyas.13968] [Citation(s) in RCA: 273] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 08/23/2018] [Indexed: 12/15/2022]
Abstract
Vitamin D is an essential nutrient for bone health and may influence the risks of respiratory illness, adverse pregnancy outcomes, and chronic diseases of adulthood. Because many countries have a relatively low supply of foods rich in vitamin D and inadequate exposure to natural ultraviolet B (UVB) radiation from sunlight, an important proportion of the global population is at risk of vitamin D deficiency. There is general agreement that the minimum serum/plasma 25-hydroxyvitamin D concentration (25(OH)D) that protects against vitamin D deficiency-related bone disease is approximately 30 nmol/L; therefore, this threshold is suitable to define vitamin D deficiency in population surveys. However, efforts to assess the vitamin D status of populations in low- and middle-income countries have been hampered by limited availability of population-representative 25(OH)D data, particularly among population subgroups most vulnerable to the skeletal and potential extraskeletal consequences of low vitamin D status, namely exclusively breastfed infants, children, adolescents, pregnant and lactating women, and the elderly. In the absence of 25(OH)D data, identification of communities that would benefit from public health interventions to improve vitamin D status may require proxy indicators of the population risk of vitamin D deficiency, such as the prevalence of rickets or metrics of usual UVB exposure. If a high prevalence of vitamin D deficiency is identified (>20% prevalence of 25(OH)D < 30 nmol/L) or the risk for vitamin D deficiency is determined to be high based on proxy indicators (e.g., prevalence of rickets >1%), food fortification and/or targeted vitamin D supplementation policies can be implemented to reduce the burden of vitamin D deficiency-related conditions in vulnerable populations.
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Affiliation(s)
- Daniel E Roth
- Department of Paediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Steven A Abrams
- Department of Pediatrics, Dell Medical School at the University of Texas at Austin, Austin, Texas
| | - John Aloia
- NYU Winthrop Hospital, Mineola, New York
| | - Gilles Bergeron
- The Sackler Institute for Nutrition Science, The New York Academy of Sciences, New York, New York
| | - Megan W Bourassa
- The Sackler Institute for Nutrition Science, The New York Academy of Sciences, New York, New York
| | | | - Mona S Calvo
- Retired, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Kevin D Cashman
- Cork Centre for Vitamin D and Nutrition Research, University College Cork, Cork, Ireland
| | | | | | | | - Kerry S Jones
- MRC Elsie Widdowson Laboratory, Cambridge, United Kingdom
| | | | - Adrian R Martineau
- Blizard Institute, Queen Mary University of London, London, United Kingdom
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Leyvraz M, Aaron GJ, Poonawala A, van Liere MJ, Schofield D, Myatt M, Neufeld LM. Coverage of Nutrition Interventions Intended for Infants and Young Children Varies Greatly across Programs: Results from Coverage Surveys in 5 Countries. J Nutr 2017; 147:995S-1003S. [PMID: 28404839 PMCID: PMC5404212 DOI: 10.3945/jn.116.245407] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 01/06/2017] [Accepted: 02/07/2017] [Indexed: 11/14/2022] Open
Abstract
Background: The efficacy of a number of interventions that include fortified complementary foods (FCFs) or other products to improve infant and young child feeding (IYCF) is well established. Programs that provide such products free or at a subsidized price are implemented in many countries around the world. Demonstrating the impact at scale of these programs has been challenging, and rigorous information on coverage and utilization is lacking.Objective: The objective of this article is to review key findings from 11 coverage surveys of IYCF programs distributing or selling FCFs or micronutrient powders in 5 countries.Methods: Programs were implemented in Ghana, Cote d'Ivoire, India, Bangladesh, and Vietnam. Surveys were implemented at different stages of program implementation between 2013 and 2015. The Fortification Assessment Coverage Toolkit (FACT) was developed to assess 3 levels of coverage (message: awareness of the product; contact: use of the product ≥1 time; and effective: regular use aligned with program-specific goals), as well as barriers and factors that facilitate coverage. Analyses included the coverage estimates, as well as an assessment of equity of coverage between the poor and nonpoor, and between those with poor and adequate child feeding practices.Results: Coverage varied greatly between countries and program models. Message coverage ranged from 29.0% to 99.7%, contact coverage from 22.6% to 94.4%, and effective coverage from 0.8% to 88.3%. Beyond creating awareness, programs that achieved high coverage were those with effective mechanisms in place to overcome barriers for both supply and demand.Conclusions: Variability in coverage was likely due to the program design, delivery model, quality of implementation, and product type. Measuring program coverage and understanding its determinants is essential for program improvement and to estimate the potential for impact of programs at scale. Use of the FACT can help overcome this evidence gap.
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Affiliation(s)
- Magali Leyvraz
- Global Alliance for Improved Nutrition, Geneva, Switzerland; and
| | - Grant J Aaron
- Global Alliance for Improved Nutrition, Geneva, Switzerland; and
| | - Alia Poonawala
- Global Alliance for Improved Nutrition, Geneva, Switzerland; and
| | | | | | - Mark Myatt
- Brixton Health, Llawryglyn, United Kingdom
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