Coverage of Large-Scale Food Fortification of Edible Oil, Wheat Flour, and Maize Flour Varies Greatly by Vehicle and Country but Is Consistently Lower among the Most Vulnerable: Results from Coverage Surveys in 8 Countries

The Policy of Compulsory Large-Scale Food Fortification in Sub-Saharan Africa

Food fortification with micronutrients was initially justified in developed countries by a lack of availability of micronutrients in staple crops, mainly due to soil exhaustion. However, in Sub-Saharan arable lands, soil fatigue is not predominant, and communities consume mostly home-grown, organic, non-processed crops. Sub-Saharan food systems are nevertheless deeply entwined with food insecurity, driver of illnesses. Family production can promote subsistence, food stability, and self-sufficiency, the main SSA setback being the vicious cycle of poverty and the lack of dietary variety, contributing to malnutrition. Poverty reduction and women's education are significant strategies for reducing child and adolescent undernourishment. Fortification of foods consumed daily by individuals makes sense and can minimize, if not entirely, eliminate deficiencies. Compulsory mass fortification of foods in Sub-Saharan Africa (SSA) with single micronutrients is, however, controversial since they work in synergy among each other and with the food matrix, for optimal absorption and metabolism. Since the causes of malnutrition are many, caused by diverse, unequal, and unjust food distribution, interrelated with political, social, cultural, or economic factors, education status of the population, season and climatic changes, and effectiveness of nutrition programs, just food fortification cannot solve the composite of all these elements. Further, compulsory fortification is excessive, unproductive, and likely harmful to human health, while many challenges remain in assessing the quality of available premixes. Furthermore, aiming at dietary diversification is the best approach of increasing trace element intake from commonly accessible and easily available food sources.

The potential contributions of bouillon fortification to meeting micronutrient requirements among women and preschool children in Senegal: A modeling study using household consumption and expenditure survey data

To reduce micronutrient deficiencies, Senegal mandates the fortification of refined oil with vitamin A and wheat flour with iron and folic acid. Expanding Senegal's large-scale food fortification programs to include fortified bouillon could help fill the remaining gaps in dietary micronutrient requirements. Using 7-day household food consumption data collected between 2018 and 2019, we assessed the potential contributions of bouillon fortified with vitamin A (40-250 μg/g bouillon), folic acid (20-120 μg/g), vitamin B12 (0.2-2 μg/g), iron (0.6-5 mg/g), and zinc (0.6-5 mg/g) for meeting micronutrient requirements of women of reproductive age (WRA; 15-49 years old) and children (6-59 months old). Most households (90%) reported consuming bouillon, including poor and rural households. At modeled fortification levels, bouillon fortification reduced the national prevalence of inadequacy by up to ∼20 percentage points (pp) for vitamin A, 34 pp (WRA) and 20 pp (children) for folate, 20 pp for vitamin B12, 38 pp (WRA) and 30 pp (children) for zinc, and ∼8 pp for iron. Predicted reductions in inadequacy were generally larger among poor and rural populations, especially for vitamins A and B12. Our modeling suggests that bouillon fortification has the potential to substantially reduce dietary inadequacy of multiple micronutrients and could also help address inequities in dietary micronutrient inadequacies in Senegal.

Mandatory large-scale food fortification programmes can reduce the estimated prevalence of inadequate zinc intake by up to 50% globally

Large-scale food fortification (LSFF) can increase dietary micronutrient intake and improve micronutrient status. Here we used food balance sheet data from the Food and Agriculture Organization of the United Nations to estimate current country-specific prevalences of inadequate zinc intake. We assessed the potential effects of improving existing LSFF programmes for cereal grains or implementing new programmes in 40 countries where zinc deficiency is a potential public health problem. Accounting for LSFF programmes as currently implemented, 15% of the global population (1.13 billion individuals) is estimated to have inadequate zinc intake. In countries where zinc deficiency is a potential public health problem, the implementation of high-quality mandatory LSFF programmes that include zinc as a fortificant would substantially increase the availability of zinc in the national food supply, reducing the estimated prevalence of inadequate zinc intake by up to 50% globally. Investments in strong LSFF programmes could have a substantial impact on population zinc status.

Micronutrient-fortified bouillon as a strategy to improve the micronutrient adequacy of diets in Burkina Faso

Bouillon is a promising candidate for fortification to complement existing large-scale food fortification (LSFF) programs. We used household dietary data from Burkina Faso to model potential contributions of bouillon fortified with vitamin A (40-250 μg/g bouillon), folic acid (20-120 μg/g), vitamin B12 (0.2-2 μg/g), iron (0.6-5 mg/g), and zinc (0.6-5 mg/g) for meeting micronutrient requirements of women of reproductive age (15-49 years; WRA) and children (6-59 months). Most households (82%) reported bouillon consumption, with higher proportions of resource-constrained (84-88%) and rural households (88%) consuming bouillon. Accounting for the contributions of existing LSFF, household diets were inadequate to meet the micronutrient requirements of many WRA and children, exceeding 90% and 60% inadequacy for vitamins A and B12, respectively. Modeling results showed bouillon fortification could reduce inadequacy by up to ∼30 percentage points (pp) for vitamin A, ∼26 pp for folate among WRA (∼11 pp among children), ∼38 pp for vitamin B12, and 11-13 pp for zinc, with comparable reductions across socioeconomic strata and urban and rural residence. Predicted reductions in iron inadequacy were <3 pp. These results suggest dietary micronutrient inadequacies are a concern in Burkina Faso, and fortified bouillon can make substantial contributions to reducing micronutrient inadequacies, including among resource-constrained and rural populations.

Assessment of the policy enabling environment for large-scale food fortification: A novel framework with an application to Kenya

Large-scale food fortification (LSFF) programs have potential to improve a population's nutritional status. Though their success depends heavily on the prevailing policy environment, few tools exist to understand this environment. To address this gap, we develop a novel framework to define and assess the policy enabling environment for LSFF. This easy-to-apply framework can be used in any setting to track progress and identify next steps for continued improvements. The policy enabling environment is conceptualized as having three domains-policy agenda setting, policy implementation, and policy monitoring and evaluation-each of which is captured through indicators that can be evaluated using existing documentation, key informant interviews, and/or a survey of stakeholder perceptions. To validate the framework and demonstrate how it can be operationalized, we apply it in Kenya, where a mandatory LSFF program for salt has been in place since 1978, and a program for packaged maize and wheat flours and vegetable oils was introduced in 2012. Per our assessment, Kenya has achieved the greatest success within the domain of policy agenda setting, has realized moderate success in policy implementation, and has a weaker record in policy monitoring and evaluation. The positive trajectory for many indicators points to a promising future for Kenya's LSFF program. This assessment yields policy implications for Kenya to improve its policy environment for LSFF, especially around financial sustainability of the program; ways to improve the processes for surveillance and enforcement; efforts to support fortification among medium-and small-scale millers; and a need to improve the data landscape.

Voice, access, and ownership: enabling environments for nutrition advocacy in India and Nigeria

What constitutes an enabling environment for nutrition advocacy in low- and middle-income countries? While a sizeable body of scholarship considers the enabling environment for nutrition policy, we focus specifically on the necessary conditions for advocacy. We argue that three factors-voice, access, and ownership-provide a useful lens into the advocacy enabling environment. These are operationalized, respectively, as the space to articulate and frame policy positions, entry points to interact with policy decision makers, and the existence of committed decision makers rather than those responding to pressures from external actors. These three factors are explored vis-à-vis a comparative analysis of two federal democracies-India and Nigeria-that each have vibrant advocacy communities confronting persistent malnutrition. Drawing on more than 100 structured interviews with nutrition advocates, government actors, donors, and researchers in the two countries, we highlight the ways in which voice, access, and ownership interactively shape advocacy efforts. In doing so, we find that Nigeria has a less ideological approach to certain nutrition issues than in India but also perceived to be more beholden to external actors in defining its nutrition actions. Recent restrictions on freedom of speech and association shrunk the civic space in India but these were less problematic in Nigeria. In both countries, the multi-tiered, multi-party system offers many different points of access into the policy arena, with sometimes negative implications for coordination. Overall, the paper contributes more broadly to the literature on enabling environments by highlighting potential indicators to guide nutrition advocates in other settings.

Daily consumption of γ-oryzanol-fortified canola oil, compared with unfortified canola and sunflower oils, resulted in a better improvement of certain cardiometabolic biomarkers of adult subjects with type 2 diabetes: a randomized controlled clinical trial

BACKGROUND

This study was undertaken to examine the effects of daily consumption of γ-oryzanol (ORZ)-fortified canola oil, as compared with plain canola and sunflower oils, on certain cardiometabolic indicators.

METHODS

Ninety-two adult subjects from both sexes with T2D were randomly assigned to one of the three groups to receive: (a) ORZ-fortified canola oil (Group 1; n1 = 30); (b) unfortified canola oil (Group 2; n2 = 32); or (c) sunflower oil (Group 3; n3 = 30) for 12 weeks. The participants were instructed to use only the given oils for all cooking (but frying) purposes. Anthropometric, dietary and biochemical assessments were done initially and finally.

RESULTS

Though body mass index (BMI) significantly decreased in all three groups, only in Groups 1 and 2 waist circumference (WC) showed a significant decrement (-2.6 ± 0.1 and -2.2 ± 0.1 cm in Groups 1 and 2 respectively, p < 0.001 for both) which was accompanied by a significant reduction of blood pressure just in Group 1. Fasting blood glucose (FBG) and glycated hemoglobin (HbA1c) showed a significant decrease only in ORZ-fortified canola oil group (-7.7 ± 0.4 mg/dL, p = 0.039 and -0.7 ± 0.1%, p < 0.001, respectively). However, insulin resistance, as judged by HOMA-IR, did not change significantly. In addition, serum triglyceride (TG) concentrations decreased in all three groups but only in ORZ-fortified canola oil was this decrement statistically significant (-17.9 ± 2.1 mg/dL, p = 0.005). Other components of serum lipid profile did not change significantly in either group.

CONCLUSIONS

Consumption of either sunflower or canola oils for 12 weeks improved certain studied biomarkers. However, only ORZ-fortified canola oil resulted in a significant decrease of blood pressure, WC, FBG, HbA1c and TG. These findings can help both clinicians and public health authorities for dietary recommendations to subjects with T2D and presumably the whole community.

TRIAL REGISTRATION

number at clinicaltrials.gov (NCT05271045).

Global Coverage of Mandatory Large-Scale Food Fortification Programs: A Systematic Review and Meta-Analysis

Food fortification with micronutrients is widely implemented to reduce micronutrient deficiencies and related outcomes. Although many factors affect the success of fortification programs, high population coverage is needed to have a public health impact. We aimed to provide recent global coverage estimates of salt, wheat flour, vegetable oil, maize flour, rice, and sugar among countries with mandatory fortification legislation. The indicators were the proportion of households consuming the: food, fortifiable food (that is, industrially processed), fortified food (to any extent), and adequately fortified food (according to national or international standards). We estimated the number of individuals reached with fortified foods. We systematically retrieved and reviewed all applicable evidence from: published reports and articles from January 2010 to August 2021, survey lists/databases from key organizations, and reports/literature received from key informants. We analyzed data with R statistical package using random-effects meta-analysis models. An estimated 94.4% of households consumed salt, 78.4% consumed fortified salt (4.2 billion people), and 48.6% consumed adequately fortified salt in 64, 84, and 31 countries, respectively. Additionally, 77.4% of households consumed wheat flour, 61.6% consumed fortifiable wheat flour, and 47.1% consumed fortified wheat flour (66.2 million people) in 15, 8, and 10 countries, respectively, and 87.0% consumed vegetable oil, 86.7% consumed fortifiable oil, and 40.1% consumed fortified oil (123.9 million people) in 10, 7, and 5 countries, respectively. Data on adequately fortified wheat flour and vegetable oil and coverage indicators for maize flour, rice, and sugar were limited. There are major data gaps on fortification coverage for most foods except salt. All countries with mandatory fortification programs should generate and use more coverage data to assess program performance and adjust programs as needed to realize their potential to reduce micronutrient deficiencies (PROSPERO CRD42021269364).

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.

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

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.

Coverage, Apparent Consumption, and Monthly Use of Packaged Maize Flour in Morogoro Region, Tanzania

INTRODUCTION

Tanzania aimed to reduce micronutrient deficiencies and neural tube defects by introducing mandatory fortification of large-scale packaged wheat and maize flour but not for small- and medium-scale mills.

OBJECTIVES

Ascertain the proportion of the population in Morogoro region, Tanzania, that consumes packaged maize flour from small-, medium- and large-mills; and understand the impact of monthly apparent purchase and consumption of packaged flour.

METHODS

In 2018, a regional, multistage cluster probability study was conducted among residents in Morogoro region living in households that reported consuming maize flour. Interviews collected information on sociodemographic factors and patterns of household flour consumption. Weighted medians estimated daily apparent flour consumption and the estimated average requirement (EAR), according to age.

RESULTS

Information was collected on 711 households. Packaged maize flour was purchased 10-12 months of the year by 22.9% of households, 6-9 months by 17.6% of households, 1-5 months by 25.1% of households, and 34.4% did not purchased maize flour. Median apparent daily consumption of maize flour was 209.7 g/d/adult male equivalent (AME). Apparent median daily consumption of maize flour was 230.1 g/d/AME in rural areas and 176.2 g/d/AME in urban areas; 228.7 g/d/AME among males and 196.4 g/d/AME among females. If all packaged maize flour were fortified according to standards, those consuming packaged maize flour 10-12 months of the year would apparently consume 199.9 µg folic acid/d representing 49.7% of daily EAR requirements.

CONCLUSIONS

Fortifying packaged maize flour at small-, medium- and large-mills is a promising strategy for increasing access to micronutrients, including folic acid.

Aligning the Epidemiology of Malnutrition with Food Fortification: Grasp Versus Reach

Large-scale food fortification (LSFF) has been recognized as one of the most cost-effective interventions to improve the intake of vitamins and minerals and decrease the burden of micronutrient deficiency. Indeed, the simple addition of micronutrients to staple foods, such as wheat, maize and rice, or condiments, including salt and bouillon, has tremendous potential to impact malnutrition. However, most LSFF programs have been poorly designed and have not taken into consideration critical inputs, including current levels of nutrient inadequacy and per capita consumption of different food vehicles when deciding which nutrients to add and at what concentrations. LSFF programs, like some other nutrition interventions, also tend to have low coverage and reach and lack monitoring to measure this and course correct. These program design flaws have resulted in limited effectiveness and have made it difficult to determine how best to harmonize LSFF with other interventions to reduce micronutrient deficiencies, including efforts to enhance dietary diversity, biofortification and supplementation. Furthermore, LSFF has often been touted as a population-based intervention, but in fact has heterogenous effects among sub-groups, particularly those with limited access to or inability to afford fortified foods, as well as those with higher physiological requirements, such as pregnant and lactating women. This article focuses on these limitations and the concerted efforts underway to improve the collection, analysis, and use of data to better plan LSFF programs, track implementation, and monitor coverage and impact. This includes a more sophisticated secondary analysis of existing data, innovations to increase the frequency of primary data collection and programmatically relevant visualizations of data of sub-national estimates. These improvements will enable better use of data to target resources and programmatic efforts to reach those who stand to benefit most from fortification.

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.

The global burden of high fasting plasma glucose associated with zinc deficiency: Results of a systematic review and meta-analysis

Non-communicable diseases (NCDs) account for the largest share of the global disease burden, and increasing evidence shows that zinc deficiency (ZD) contributes to NCDs by inducing oxidative stress, insulin resistance, and impaired lipid metabolism. A systematic review and meta-analysis was conducted to determine whether ZD was associated with fasting plasma glucose (FPG), a key risk factor for NCDs. A random effects meta-analysis was conducted to determine the strength of the association in the form of an odds ratio (OR) and subsequently the population attributable risk (PAR) with population prevalences of high FPG. The disease burden from high FPG attributable to ZD was expressed as disability adjusted life years (DALYS). Data from seven studies were obtained as part of the systematic review. The meta-analysis shows a significant (p<0.01) inverse relationship between ZD and high FPG (OR = 2.34; 95% CI: 1.16, 4.72). Globally, the PAR of ZD's contribution to high FPG is 6.7%, with approximately 8.2 million high FPG DALYs attributable to ZD. Cardiovascular diseases, diabetes, and chronic kidney diseases account for more than 90% of the total DALYs. Total DALYs attributable to ZD are largest in the "Southeast Asia, East Asia, and Oceania" and "High Income" Super Regions. While the disease burden is highest among populous countries (e.g., China, India, USA), the population-standardized DALYs are highest among island nations, particularly island nations in the South Pacific and Caribbean. While ZD accounts for a small share of the high FPG disease burden, the total number of DALYs far surpasses other estimates of the disease burden attributable to ZD, which focus on diarrheal diseases in childhood. Zinc interventions are urgently needed to help address the increasing disease burden from NCDs, and the double burden of malnutrition.

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.

Critical review of indicators, metrics, methods, and tools for monitoring and evaluation of biofortification programs at scale

Sound monitoring and evaluation (M&E) systems are needed to inform effective biofortification program management and implementation. Despite the existence of M&E frameworks for biofortification programs, the use of indicators, metrics, methods, and tools (IMMT) are currently not harmonized, rendering the tracking of biofortification programs difficult. We aimed to compile IMMT for M&E of existing biofortification programs and recommend a sub-set of high-level indicators (HLI) for a harmonized global M&E framework. We conducted (1) a mapping review to compile IMMT for M&E biofortification programs; (2) semi-structured interviews (SSIs) with biofortification programming experts (and other relevant stakeholders) to contextualize findings from step 1; and (3) compiled a generic biofortification program Theory of Change (ToC) to use it as an analytical framework for selecting the HLI. This study revealed diversity in seed systems and crop value chains across countries and crops, resulting in differences in M&E frameworks. Yet, sufficient commonalities between implementation pathways emerged. A set of 17 HLI for tracking critical results along the biofortification implementation pathway represented in the ToC is recommended for a harmonized global M&E framework. Further research is needed to test, revise, and develop mechanisms to harmonize the M&E framework across programs, institutions, and countries.

Valuing the Diversity of Research Methods to Advance Nutrition Science

The ASN Board of Directors appointed the Nutrition Research Task Force to develop a report on scientific methods used in nutrition science to advance discovery, interpretation, and application of knowledge in the field. The genesis of this report was growing concern about the tone of discourse among nutrition professionals and the implications of acrimony on the productive study and translation of nutrition science. Too often, honest differences of opinion are cast as conflicts instead of areas of needed collaboration. Recognition of the value (and limitations) of contributions from well-executed nutrition science derived from the various approaches used in the discipline, as well as appreciation of how their layering will yield the strongest evidence base, will provide a basis for greater productivity and impact. Greater collaborative efforts within the field of nutrition science will require an understanding that each method or approach has a place and function that should be valued and used together to create the nutrition evidence base. Precision nutrition was identified as an important emerging nutrition topic by the preponderance of task force members, and this theme was adopted for the report because it lent itself to integration of many approaches in nutrition science. Although the primary audience for this report is nutrition researchers and other nutrition professionals, a secondary aim is to develop a document useful for the various audiences that translate nutrition research, including journalists, clinicians, and policymakers. The intent is to promote accurate, transparent, verifiable evidence-based communication about nutrition science. This will facilitate reasoned interpretation and application of emerging findings and, thereby, improve understanding and trust in nutrition science and appropriate characterization, development, and adoption of recommendations.

The effects of vitamin D-fortified foods on circulating 25(OH)D concentrations in adults: a systematic review and meta-analysis

Improvement of vitamin D status of the general population has been a challenge for policymakers. We conducted a meta-analysis to evaluate whether vitamin D-fortified products can be a suitable solution for tackling vitamin D deficiency. Our secondary objective was to determine the effect of some variables including age, latitude and BMI on efficacy of this strategy. MEDLINE, PubMed, Embase, Cochrane Library and Google Scholar were searched and 231 studies were found in a preliminary search. After screening of titles and abstracts, 23 studies were selected. Pooled data comparing fortification with vitamin D +/- Ca with control showed statistically significant effect on total 25(OH)D concentrations (2002 participants, mean difference (MD): 25·4 nmol/l, (95 % CI 19·5, 31·3)). The subgroup analysis by duration of intervention (less than 12 weeks v. more than 12 weeks) and type of vehicle (dairy product, juice, grain product, oil and combination of dairy and grain products), isoform of the vitamin (D₃v. D₂) and dose of the fortificant (≥ 1000 IU/d v. < 1000 IU/d) also indicated significant effect of fortification with vitamin D on serum 25(OH)D concentrations. In conclusion, the circulating 25(OH)D response to vitamin D-fortified food consumption is influenced by age, BMI and the baseline 25(OH)D concentrations. Notwithstanding, an average of 2 nmol/l increase in circulating 25(OH)D concentration for each 100 IU vitamin D intake per d is expected for general adult population. These findings can be informative for policymakers to tackle vitamin D deficiency through food fortification strategy.

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.

Community Preventive Health Education Intervention for Pediatric Iron-Deficiency Anemia in Rural Southeast Nigeria

Objectives

Iron-deficiency anemia (IDA) is a global cause of morbidity in children under five, particularly in sub-Saharan Africa. In southeast Nigeria, poor dietary intake and caregiver knowledge about childhood anemia are observed; however, there is no consensus on how to best prevent it. This study seeks to test the effectiveness of caregiver education on improving anemia knowledge and dietary prevention strategies and promoting sustainable lifestyle changes to reduce the prevalence of childhood IDA.

Study Design

A questionnaire was administered to the primary caregivers of 41 patients under age five with anemia in southeast Nigeria regarding socioeconomic status (SES), diet diversity, and risk factors for anemia. Caregivers were administered a preeducation questionnaire, poster education on anemia and iron-rich foods, and a posteducation questionnaire. All patients underwent a medical exam to confirm a diagnosis of anemia or anemia-related conditions.

Results

Ninety-five percent of patients had moderate diet diversity, but there was no correlation between diet diversity and SES. Barriers to healthier diets were associated with SES. Preeducation scores were not associated with caregivers' education levels; however, posteducation scores were significantly higher in university-educated than technical-trained caregivers. Caregiver-reported self-efficacy increased after the education program.

Conclusion

Caregivers' SES was associated with financial and knowledge barriers to a healthier diet but not diet diversity, suggesting that nutritional education could benefit all SES groups. Overall, the education program increased caregivers' anemia knowledge across educational levels. A community-based health education program could improve caregivers' anemia knowledge and self-efficacy in applying this information and potentially reduce this area's pediatric IDA.

Determinants and drivers of young children's diets in Latin America and the Caribbean: Findings from a regional analysis

The Latin America and Caribbean region exhibit some of the lowest undernutrition rates globally. Yet, disparities exist between and within countries and countries in the region increasingly face other pressing nutritional concerns, including overweight, micronutrient deficiencies and inadequate child feeding practices. This paper reports findings from a regional analysis to identify the determinants and drivers of children's diets, with a focus on the complementary feeding window between the age of 6-23 months. The analysis consists of a narrative review and descriptive data analysis, complemented with qualitative interviews with key informants in four countries: Guatemala, Paraguay, Peru and Uruguay. Findings indicate that poverty and inequality (disparities within countries by wealth and residence), unequal access to services, inadequate coverage of social programmes and lack of awareness on appropriate feeding practices are important drivers for inadequate diets. We conclude that countries in the region need to invest in policies to tackle overweight and micronutrient deficiencies in young children, considering inequalities between and within countries, enhance coverage of social protection programmes, improve coordination between sectors to improve children's diets and expand the coverage and intensity of awareness campaigns on feeding practices, using iterative programme designs.

Understanding drivers of private-sector compliance to large-scale food fortification: A case study on edible oil value chains in Bangladesh

Micronutrient deficiency is a pertinent global challenge that affects billions of people and has deleterious health effects. Large-scale food fortification (LSFF) is a cost- effective way to tackle micronutrient deficiency and improve health outcomes, particularly in low- and middle-income countries (LMICs). However, the success of LSFF in LMICs is often hampered by limited compliance with fortification mandates by the private sector, who supply fortified foods. In this paper, we use a case study of the edible oil produced in Bangladesh to analyze the factors facilitating and impeding this compliance by for-profit actors. We identified four bottlenecks that disincentivize private sector actors' decision to comply. First, fortified and non-fortified products co-exist in the market, disincentivizing producers to invest in fortification. Second, the lack of traceability reduces the risk for large-scale producers' non-compliance with the regulation. Third, small-scale producers face economic pressures that prevent them from adequately fortifying oil products. Lastly, law enforcement is currently inconsistent, allowing the supply of under-fortified oil in the market. Given the evidence, we recommend to strengthen the control of bulk item fortification through more frequent and rigorous surveillance at the production level. This will ensure that resource constrained consumers who also have the greatest potential to benefit from added nutrients, remain able to access affordable and nutrient-enriched food.

Firm's compliance behaviour towards food fortification regulations: Evidence from oil and salt producers in Bangladesh

Impact of national food fortification programs is contingent on the extent to which there is compliance with national standards. However, this compliance is often sub-optimal and is not consistently measured. One of the challenges to more regular measurement is an over-reliance on quantitative assessments of micronutrient levels for compliance, which are costly. In resource constrained environments, this contributes to weaknesses in regulatory monitoring. We offer an alternative, systems-based approach to determine compliance, presenting a unique score that can capture firms' compliance behaviour, based on whether and how firms actually carry out stages of the fortification process. The key utility of such a measure being its use to monitor fortification propensity and assess changes in response to interventions. Further, we present an empirical application of this measure, providing novel evidence on firms' compliance towards food fortification regulations in Bangladesh, investigating the institutional and firm-level factors that correlate with compliance behaviour towards food fortification regulations among edible oil and salt producers.

Systematic Process Framework for Conducting Implementation Science Research in Food Fortification Programs

Many challenges still exist to fully scaling up food fortification in lower resource settings. To address this need, a collective group of experts in the fields of food fortification and implementation science developed a systematic process framework to provide a tool for identifying and working through challenges.

Food fortification has proven to be an effective approach for preventing micronutrient deficiencies in many settings. Factors that lead to successful fortification programs are well established. However, due to the multisectoral nature of fortification and the added complexities present in many settings, the barriers to success are not always evident and the strategies to address them are not always obvious. We developed a systematic process for identifying and addressing gaps in the implementation of a food fortification program. The framework is composed of 4 phases: (1) connect program theory of change to program implementation; (2) develop an implementation research agenda; (3) conduct implementation research; and (4) analyze findings and develop/disseminate recommendations for next steps. We detail steps in each phase to help guide teams through the process. To our knowledge, this is the first attempt to outline a systematic process for applying implementation science research to food fortification. The development of this framework is intended to promote implementation research in the field of food fortification, thus improving access to and effectiveness of this key public health intervention.

Examining Heterogeneity of Food Fortification and Biofortification Business Models: Emerging Evidence for a Typology

Efforts to address Micronutrient deficiencies (MNDs) in lower-and middle-income countries (LMICs) have been gaining pace in recent years. Commodities such as staple foods (e.g., cereals, roots, and tubers) and condiments (e.g., salt) have been targeted as ‘vehicles’ for fortification and biofortification through numerous projects and initiatives. To date, there have been mixed experiences with delivery and coverage with very little documented on the range of business models applied in different geographies, business conditions and polities and this makes classification and measurement of success and failure difficult. This research aims to address this gap in knowledge through proposing a typology that clarifies similarities (internal heterogeneity) and differences (external heterogeneity) between models and that can allow all types to be defined by the combination of attributes. Building on a comprehensive literature review; NVivo was used to code initiatives from 34 key references (955 cases in total) which have been grouped into 17 categories. Using non-metric multidimensional scaling (NMDS) we find evidence of four business model groupings that typify fortification initiatives: (1) Large-scale private, unregulated, (2) Mixed-Scale, private, unregulated (3) Large-scale, public-private, regulated; and (4) Large-scale, private, regulated. We characterise these four groups with country examples and suggest that this typology can help the discourse around viability of food fortification initiatives.

Scaling Up Delivery of Biofortified Staple Food Crops Globally: Paths to Nourishing Millions

BACKGROUND

Micronutrient deficiencies affect over one quarter of the world's population. Biofortification is an evidence-based nutrition strategy that addresses some of the most common and preventable global micronutrient gaps and can help improve the health of millions of people. Since 2013, HarvestPlus and a consortium of collaborators have made impressive progress in the enrichment of staple crops with essential micronutrients through conventional plant breeding.

OBJECTIVE

To review and highlight lessons learned from multiple large-scale delivery strategies used by HarvestPlus to scale up biofortification across different country and crop contexts.

RESULTS

India has strong public and private sector pearl millet breeding programs and a robust commercial seed sector. To scale-up pearl millet, HarvestPlus established partnerships with public and private seed companies, which facilitated the rapid commercialization of products and engagement of farmers in delivery activities. In Nigeria, HarvestPlus stimulated the initial acceptance and popularization of vitamin A cassava using a host of creative approaches, including "crowding in" delivery partners, innovative promotional programs, and development of intermediate raw material for industry and novel food products. In Uganda, orange sweet potato (OSP) is a traditional subsistence crop. Due to this, and the lack of formal seed systems and markets, HarvestPlus established a network of partnerships with community-based nongovernmental organizations and vine multipliers to popularize and scale-up delivery of OSP.

CONCLUSIONS

Impact of biofortification ultimately depends on the development of sustainable markets for biofortified seeds and products. Results illustrate the need for context-specific, innovative solutions to promote widespread adoption.

Vitamin A Fortification Quality Is High for Packaged and Branded Edible Oil but Low for Oil Sold in Unbranded, Loose Form: Findings from a Market Assessment in Bangladesh

Although mandatory fortification of oil with vitamin A is efficacious, its effectiveness can be compromised by suboptimal compliance to standards. In this study, we assessed (1) the availability of oil brands across the eight divisions of Bangladesh, (2) fortification quality (the extent to which vitamin A content is aligned with fortification standards) of oil brands and producers and (3) the market volume represented by available edible oil types. We visited different retail outlets in rural and urban market hubs to ascertain available oil brands and bulk oil types and collected samples. We used high-performance liquid chromatography to quantify average vitamin A content and compared them to the national oil fortification standards. Among the 66 packaged brands analyzed, 26 (39%) were not fortified, and 40 (61%) were fortified, with 28 (42%) fortified above the standard vitamin A minimum. Among the 41 bulk oil type composites analyzed, 24 (59%) were not fortified, and 17 (41%) were fortified, with 14 (34%) fortified below and 3 (7%) fortified above the standard minimum. Vitamin A fortification is high for packaged and branded edible oil but low for oil sold in unbranded, loose form. As bulk oil makes up a large proportion of the oil market volume, this means the majority of the oil volume available to the population is either not (25%) or fortified below the standard requirement (39%). Regulatory inspections of producers selling bulk oil should be prioritized to support and incentivize the industry to make all oil traceable and fortified to standard.

The Potential of Iodine and Iron Double-Fortified Salt Compared with Iron-Fortified Staple Foods to Increase Population Iron Status

The potential of double-fortified salt (DFS) to improve population iron status is compared with the potential of iron-fortified wheat flour, maize flour, rice grains, and milk products. The potential for a positive impact on iron status is based on reported efficacy studies, consumption patterns, the extent of industrialization, and whether there are remaining technical issues with the fortification technologies. Efficacy studies with DFS, and with iron-fortified wheat flour, maize flour, and rice, have all reported good potential to improve population iron status. Iron-fortified milk powder has shown good impact in young children. When these foods are industrially fortified in modern, automated facilities, with high-level quality control and assurance practices, high-quality raw materials, and a wide population coverage, all vehicles have good potential to improve iron status. Relative to other fortification vehicles, fortification practices with wheat flour are the most advanced and iron-fortified wheat flour has the highest potential for impact in the short- to medium-term in countries where wheat flour is consumed as a staple. Liquid milk has the least potential, mainly because an acceptable iron fortification technology has not yet been developed. Maize is still predominantly milled in small-scale local mills and, although the extruded rice premix technology holds great promise, it is still under development. Salt has a proven record as an excellent vehicle for iodine fortification and has demonstrated good potential for iron fortification. However, technical issues remain with DFS and further studies are needed to better understand and avoid color formation and iron-catalyzed iodine losses in both high- and low-quality salts under different storage conditions. There is currently a risk that the introduction of DFS may jeopardize the success of existing salt iodization programs because the addition of iron may increase iodine losses and cause unacceptable color formation.

Assessing the Coverage of Biofortified Foods: Development and Testing of Methods and Indicators in Musanze, Rwanda

BACKGROUND

Biofortification of staple crops has the potential to increase nutrient intakes and improve health outcomes. Despite program data on the number of farming households reached with and growing biofortified crops, information on the coverage of biofortified foods in the general population is often lacking. Such information is needed to ascertain potential for impact and identify bottlenecks to parts of the impact pathway.

OBJECTIVES

We aimed to develop and test methods and indicators for assessing household coverage of biofortified foods.

METHODS

To assess biofortification programs, 5 indicators of population-wide household coverage were developed, building on approaches previously used to assess large-scale food fortification programs. These were 1) consumption of the food; 2) awareness of the biofortified food; 3) availability of the biofortified food; 4) consumption of the biofortified food (ever); and 5) consumption of the biofortified food (current). To ensure that the indicators are applicable to different settings they were tested in a cross-sectional household-based cluster survey in rural and peri-urban areas in Musanze District, Rwanda where planting materials for iron-biofortified beans (IBs) and orange-fleshed sweet potatoes (OFSPs) were delivered.

RESULTS

Among the 242 households surveyed, consumption of beans and sweet potatoes was 99.2% and 96.3%, respectively. Awareness of IBs or OFSPs was 65.7% and 48.8%, and availability was 23.6% and 10.7%, respectively. Overall, 15.3% and 10.7% of households reported ever consuming IBs and OFSPs, and 10.4% and 2.1% of households were currently consuming these foods, respectively. The major bottlenecks to coverage of biofortified foods were awareness and availability.

CONCLUSIONS

These methods and indicators fill a gap in the availability of tools to assess coverage of biofortified foods, and the results of the survey highlight their utility for identifying bottlenecks. Further testing is warranted to confirm the generalizability of the coverage indicators and inform their operationalization when deployed in different settings.

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

BACKGROUND

Food fortification is implemented to increase intakes of specific nutrients in the diet, but contributions of fortified foods to nutrient intakes are rarely quantified.

OBJECTIVES

We quantified iron, vitamin A, and iodine intakes from fortified staple foods and condiments among women of reproductive age (WRA).

METHODS

In subnational (Nigeria, South Africa) and national (Tanzania, Uganda) cross-sectional, clustered household surveys, we assessed fortifiable food consumption. We estimated daily nutrient intakes from fortified foods among WRA by multiplying the daily apparent fortifiable food consumption (by adult male equivalent method) by a fortification content for the food. Two fortification contents were used: measured, based on the median amount quantified from individual food samples collected from households; and potential, based on the targeted amount in national fortification standards. Results for both approaches are reported as percentages of the estimated average requirement (EAR) and recommended nutrient intake (RNI).

RESULTS

Fortified foods made modest contributions to measured iron intakes (0%-13% RNI); potential intakes if standards are met were generally higher (0%-65% RNI). Fortified foods contributed substantially to measured vitamin A and iodine intakes (20%-125% and 88%-253% EAR, respectively); potential intakes were higher (53%-655% and 115%-377% EAR, respectively) and would exceed the tolerable upper intake level among 18%-56% of WRA for vitamin A in Nigeria and 1%-8% of WRA for iodine in Nigeria, Tanzania, and Uganda.

CONCLUSIONS

Fortified foods are major contributors to apparent intakes of vitamin A and iodine, but not iron, among WRA. Contributions to vitamin A and iodine are observed despite fortification standards not consistently being met and, if constraints to meeting standards are addressed, there is risk of excessive intakes in some countries. For all programs assessed, nutrient intakes from all dietary sources and fortification standards should be reviewed to inform adjustments where needed to avoid risk of low or excessive intakes.

Role of home visits by volunteer community health workers: to improve the coverage of micronutrient powders in rural Bangladesh

OBJECTIVE

We assessed the role of home visits by Shasthya Shebika (SS) - female volunteer community health workers (CHWs) - in improving the distribution of micronutrient powder (MNP), and explored the independent effects of caregiver-provider interaction on coverage variables.

DESIGN

We used data from three cross-sectional surveys undertaken at baseline (n 1927), midline (n 1924) and endline (n 1540) as part of an evaluation of a home fortification programme. We defined an exposure group as one that had at least one SS visit to the caregiver's household in the 12 months preceding the survey considering three outcome variables - message (ever heard), contact (ever used) and effective coverage (regular used) of MNP. We performed multiple logistic regressions to explore the determinants of coverage, employed an 'interaction term' and calculated an odds ratio (OR) to assess the modifying effect of SS's home visits on coverage.

SETTINGS

Sixty-eight sub-districts from ten districts of Bangladesh.

PARTICIPANTS

Children aged 6-59 months and their caregivers.

RESULTS

A home visit from an SS positively impacts message coverage at both midline (ratio of OR 1·70; 95 % CI 1·25, 2·32; P < 0·01) and endline (ratio of OR 3·58; 95 % CI 2·22, 5·78; P < 0·001), and contact coverage both at midline (ratio of OR 1·48; 95 % CI 1·06, 2·07; P = 0·021) and endline (ratio of OR 1·74; 95 % CI 1·23, 2·47; P = 0·002). There was no significant effect of a SS's home visit on effective coverage.

CONCLUSIONS

The households visited by BRAC's volunteer CHWs have better message and contact coverage among the children aged 6-59 months.

Hutton Z, Fattore G, Sabatier M, Detzel P. Reducing the burden of iron deficiency anemia in Cote D'Ivoire through fortification

BACKGROUND

Iron deficiency anemia (IDA) is highly prevalent in the Cote d'Ivoire and has severe health and economic consequences. In this paper, we apply a health economic model to quantify the burden of IDA, and the contribution of nationwide mandatory iron fortification of wheat flour and voluntary iron fortification of condiments to the reduction of this burden.

METHODS

The analysis for the population from 6 months to 64 years builds on published reviews and publicly available datasets and is stratified by age-groups and socioeconomic strata using comparative risk assessment model.

RESULTS

Without the impact of these fortification strategies, the annual burden of IDA is estimated at 242,100 disability adjusted life years (DALYs) and 978.1 million USD. Wheat flour and condiment fortification contributed to a reduction of the IDA burden by approximately 5% each.

CONCLUSION

In places with high prevalence of malaria and other infectious diseases, such as the Côte D'Ivoire, food fortification as a nutritional intervention should be accompanied with infectious disease prevention and control. The findings of this study provide additional input for policy makers about the magnitude of the impact and can support the conception of future fortification strategies.

The Unfinished Agenda for Food Fortification in Low- and Middle-Income Countries: Quantifying Progress, Gaps and Potential Opportunities

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.

Strategies to achieve adequate vitamin A intake for young children: options for Cameroon

Meeting children's vitamin A (VA) needs remains a policy priority. Doing so efficiently is a fiscal imperative and protecting at-risk children during policy transitions is a moral imperative. Using the Micronutrient Intervention Modeling tool and data for Cameroon, we predict the impacts and costs of alternative VA intervention programs, identify the least-cost strategy for meeting targets nationally, and compare it to a business-as-usual (BAU) strategy over 10 years. BAU programs effectively cover ∼12.8 million (m) child-years (CY) and cost ∼$30.1 m; ∼US$2.34 per CY effectively covered. Improving the VA-fortified oil program, implementing a VA-fortified bouillon cube program, and periodic VA supplements (VAS) in the North macroregion for 3 years effectively cover ∼13.1 m CY at a cost of ∼US$9.5 m, or ∼US$0.71 per CY effectively covered. The tool then identifies a sequence of subnational policy choices leading from the BAU toward the more efficient strategy, while addressing VA-attributable mortality concerns. By year 4, fortification programs are predicted to eliminate inadequate VA intake in the South and Cities macroregions, but not the North, where VAS should continue until additional delivery platforms are implemented. This modeling approach offers a concrete example of the strategic use of data to follow the Global Alliance for VA framework and do so efficiently.

Monitoring of the National Oil and Wheat Flour Fortification Program in Cameroon Using a Program Impact Pathway Approach

BACKGROUND

Since 2011 Cameroon has mandated the fortification of refined vegetable oil with vitamin A and wheat flour with iron, zinc, folic acid, and vitamin B-12. In 2012, measured fortification levels for flour, and particularly oil, were below target.

OBJECTIVES

We assessed Cameroon's food fortification program using a program impact pathway (PIP) to identify barriers to optimal performance.

METHODS

We developed a PIP through literature review and key informant interviews. We conducted interviews at domestic factories for refined vegetable oil (n = 9) and wheat flour (n = 10). In 12 sentinel sites distributed nationally, we assessed availability and storage conditions of fortified foods in markets and frequency of consumption of fortified foods among women and children (n = 613 households). Food samples were collected from factories, markets, and households for measurement of micronutrient content.

RESULTS

Two-thirds of factories presented quality certificates for recent premix purchases. All factories had in-house capacity for micronutrient analysis, but most used qualitative methods. Industries cited premix import taxes and access to external laboratories as constraints. Mean vitamin A levels were 141% (95% CI: 116%, 167%), 75% (95% CI: 62%, 89%), and 75% (95% CI: 60%, 90%) of target in individual samples from factories, markets, and households, respectively. Most industry flour samples appeared to be fortified, but micronutrient levels were low. Among composite flour samples from markets and households, the mean iron and zinc content was 25 mg/kg and 43 mg/kg, respectively, ∼45% of target levels; folic acid (36%) and vitamin B-12 (29%) levels were also low. In the previous week, the majority of respondents had consumed "fortifiable" oil (63% women and 52% children) and wheat flour (82% women and 86% children).

CONCLUSIONS

In Cameroon, oil fortification program performance appears to have improved since 2012, but fortification levels remain below target, particularly for wheat flour. Consistent regulatory monitoring and program support, possibly through premix procurement and micronutrient analysis, are needed.

Which Choice of Delivery Model(s) Works Best to Deliver Fortified Foods?

Micronutrient deficiencies (MNDs) occur as a result of insufficient intake of minerals and vitamins that are critical for body growth, physical/mental development, and activity. These deficiencies are particularly prevalent in lower-and middle-income countries (LMICs), falling disproportionately on the poorest and most vulnerable segments of the society. Dietary diversity is considered the most effective method in reducing this deficiency but is often a major constraint as most foods rich in micronutrients are also expensive and thereby inaccessible to poorer members of society. In recent years, affordable commodities such as staple foods (e.g., cereals, roots, and tubers) and condiments (e.g., salt and oil) have been targeted as "vehicles" for fortification and biofortification. Despite efforts by many countries to support such initiatives, there have been mixed experiences with delivery and coverage. An important but little understood driver of success and failure for food fortification has been the range of business models and approaches adopted to promote uptake. This review examines the different models used in the delivery of fortified food including complementary foods and biofortified crops. Using a keyword search and pearl growing techniques, the review located 11,897 texts of which 106 were considered relevant. Evidence was found of a range of business forms and models that attempt to optimise uptake, use, and impact of food fortification which are specific to the 'food vehicle' and environment. We characterise the current business models and business parameters that drive successful food fortification and we propose an initial structure for understanding different fortification business cases that will offer assistance to future designers and implementors of food fortification programmes.

Estimating reach of social impact products: A model to standardize the calculation of product reach in data-scarce settings

Background

Social impact interventions often involve the introduction of a product intended to create positive impact. Program decision makers need data to routinely review product delivery as well as predict potential outcomes and impact to optimize intervention plans and allocate resources effectively. We propose a novel model to support data-driven decision-making in data and budget-constrained settings and use of routine monitoring to ensure progress towards program outcomes and impact.

Methods

We present a complete model to estimate product reach of durable and fast-moving consumer products, which includes required inputs, potential data sources, formulas, trade-offs, and assumptions.

Results

We illustrate the use of the model by applying it to the case study of fortified rice introduction in Brazil and estimate that the intervention, which aimed to improve nutrition status and health outcomes reached 2.4 million consumers.

Conclusions

The model can cover a broad range of social-purpose interventions that involve the introduction or scale-up of various types of consumer products. It provides a relatively simple, comprehensive, flexible, and usable framework to estimate product reach, an indicator that can be an input into impact estimates or, in many scenarios, the actual endpoint of the intervention.

Advances in the measurement of coverage for RMNCH and nutrition: from contact to effective coverage

Current methods for measuring intervention coverage for reproductive, maternal, newborn, and child health and nutrition (RMNCH+N) do not adequately capture the quality of services delivered. Without information on the quality of care, it is difficult to assess whether services provided will result in expected health improvements. We propose a six-step coverage framework, starting from a target population to (1) service contact, (2) likelihood of services, (3) crude coverage, (4) quality-adjusted coverage, (5) user-adherence-adjusted coverage and (6) outcome-adjusted coverage. We support our framework with a comprehensive review of published literature on effective coverage for RMNCH+N interventions since 2000. We screened 8103 articles and selected 36 from which we summarised current methods for measuring effective coverage and computed the gaps between ‘crude’ coverage measures and quality-adjusted measures. Our review showed considerable variability in data sources, indicator definitions and analytical approaches for effective coverage measurement. Large gaps between crude coverage and quality-adjusted coverage levels were evident, ranging from an average of 10 to 38 percentage points across the RMNCH+N interventions assessed. We define effective coverage as the proportion of individuals experiencing health gains from a service among those who need the service, and distinguish this from other indicators along a coverage cascade that make quality adjustments. We propose a systematic approach for analysis along six steps in the cascade. Research to date shows substantial drops in effective delivery of care across these steps, but variation in methods limits comparability of the results. Advancement in coverage measurement will require standardisation of effective coverage terminology and improvements in data collection and methodological approaches.

Improved micronutrient status and health outcomes in low- and middle-income countries following large-scale fortification: evidence from a systematic review and meta-analysis

BACKGROUND

Micronutrient malnutrition is highly prevalent in low- and middle-income countries (LMICs) and disproportionately affects women and children. Although the effectiveness of large-scale food fortification (LSFF) of staple foods to prevent micronutrient deficiencies in high-income settings has been demonstrated, its effectiveness in LMICs is less well characterized. This is important as food consumption patterns, potential food vehicles, and therefore potential for impact may vary substantially in these contexts.

OBJECTIVES

The aim of this study was to determine the real-world impact of LSFF with key micronutrients (vitamin A, iodine, iron, folic acid) on improving micronutrient status and functional health outcomes in LMICs.

METHODS

All applicable published/unpublished evidence was systematically retrieved and analyzed. Studies were not restricted by age or sex. Meta-analyses were performed for quantitative outcomes and results were presented as summary RRs, ORs, or standardized mean differences (SMDs) with 95% CIs.

RESULTS

LSFF increased serum micronutrient concentrations in several populations and demonstrated a positive impact on functional outcomes, including a 34% reduction in anemia (RR: 0.66; 95% CI: 0.59, 0.74), a 74% reduction in the odds of goiter (OR: 0.26; 95% CI: 0.16, 0.43), and a 41% reduction in the odds of neural tube defects (OR: 0.59; 95% CI: 0.49, 0.70). Additionally, we found that LSFF with vitamin A could protect nearly 3 million children per year from vitamin A deficiency. We noted an age-specific effect of fortification, with women (aged >18 y) attaining greater benefit than children, who may consume smaller quantities of fortified staple foods. Several programmatic/implementation factors were also reviewed that may facilitate or limit program potential.

CONCLUSIONS

Measurable improvements in the micronutrient and health status of women and children are possible with LSFF. However, context and implementation factors are important when assessing programmatic sustainability and impact, and data on these are quite limited in LMIC studies.

Weighing the risks of high intakes of selected micronutrients compared with the risks of deficiencies

Several intervention strategies are available to reduce micronutrient deficiencies, but uncoordinated implementation of multiple interventions may result in excessive intakes. We reviewed relevant data collection instruments and available information on excessive intakes for selected micronutrients and considered possible approaches for weighing competing risks of intake above tolerable upper intake levels (ULs) versus insufficient intakes at the population level. In general, population-based surveys in low- and middle-income countries suggest that dietary intakes greater than the UL are uncommon, but simulations indicate that fortification and supplementation programs could lead to high intakes under certain scenarios. The risk of excessive intakes can be reduced by considering baseline information on dietary intakes and voluntary supplement use and continuously monitoring program coverage. We describe a framework for comparing risks of micronutrient deficiency and excess, recognizing that critical information for judging these risks is often unavailable. We recommend (1) assessing total dietary intakes and nutritional status; (2) incorporating rapid screening tools for routine monitoring and surveillance; (3) addressing critical research needs, including evaluations of the current ULs, improving biomarkers of excess, and developing methods for predicting and comparing risks and benefits; and (4) ensuring that relevant information is used in decision-making processes.

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.

Coordinating Nigeria's micronutrient deficiency control programs is necessary to prevent deficiencies and toxicity risks

Nigeria has an alarming prevalence of micronutrient deficiencies that has persisted over decades. National Micronutrient Deficiency Control (MNDC) guidelines describe several interventions to address the issue. This study identified and described currently implemented interventions, assessed coverage and coordination of the interventions, and considered the risk of overdosage and gaps. Methods included reviews of policy and program documents, key informant interviews, market, and pharmacy visits. The study found that an array of MNDC interventions were being implemented, including public health supplementation, mandatory fortification, point-of-use fortification, biofortification, promotion of dietary diversity, voluntary fortification, and ad hoc individual supplement use. Insufficient coordination existed for government, private, and civil society interventions within the health sector and between health and other sectors. Dosages of micronutrients supplied by different interventions were set independently of each other and target populations overlapped. Inadequate implementation of various interventions appeared to reduce the risk of excessive micronutrient intakes, but increased the risk of deficiencies. The risk of excessive intakes will likely increase with improved implementation and scale-up. There is a need to develop effective coordination structures for MNDC in Nigeria that will critically examine the landscape, decide modalities for different interventions, and ensure that both deficiencies and risk of excessive intakes are minimized.

Household coverage of vitamin A fortification of edible oil in Bangladesh

Mandatory fortification of edible oil (soybean and palm) with vitamin A was decreed in Bangladesh in 2013. Yet, there is a dearth of data on the availability and consumption of vitamin A fortifiable oil at household level across population sub-groups. To fill this gap, our study used a nationally representative survey in Bangladesh to assess the purchase of fortifiable edible oil among households and project potential vitamin A intake across population sub-groups. Data is presented by strata, age range and poverty-the factors that potentially influence oil coverage. Across 1,512 households, purchase of commercially produced fortifiable edible oil was high (87.5%). Urban households were more likely to purchase fortifiable oil (94.0%) than households in rural low performing (79.7%) and rural other strata (88.1%) (p value: 0.01). Households in poverty were less likely to purchase fortifiable oil (82.1%) than households not in poverty (91.4%) (p <0.001). Projected estimates suggested that vitamin A fortified edible oil would at least partially meet daily vitamin A estimated average requirement (EAR) for the majority of the population. However, certain population sub-groups may still have vitamin A intake below the EAR and alternative strategies may be applied to address the vitamin A needs of these vulnerable sub-groups. This study concludes that a high percentage of Bangladeshi population across different sub-groups have access to fortifiable edible oil and further provides evidence to support mandatory edible oil fortification with vitamin A in Bangladesh.

Global prevalence and disease burden of vitamin D deficiency: a roadmap for action in low- and middle-income countries

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.

Large-Scale Food Fortification and Biofortification in Low- and Middle-Income Countries: A Review of Programs, Trends, Challenges, and Evidence Gaps

BACKGROUND

Food fortification and biofortification are well-established strategies to address micronutrient deficiencies in vulnerable populations. However, the effectiveness of fortification programs is not only determined by the biological efficacy of the fortified foods but also by effective and sustainable implementation, which requires continual monitoring, quality assurance and control, and corrective measures to ensure high compliance.

OBJECTIVE

To provide an overview of efficacy, effectiveness, economics of food fortification and biofortification, and status of and challenges faced by large-scale food fortification programs in low- and middle-income countries (LMIC).

METHODS

A literature review of PubMed publications in English from 2000 to 2017, as well as gray literature, targeting nongovernmental organizations whose work focuses on this topic, complemented by national reports and a "snowball" process of citation searching. The article describes remaining technical challenges, barriers, and evidence gap and prioritizes recommendations and next steps to further accelerate progress and potential of impact.

RESULTS

The review identifies and highlights essential components of successful programs. It also points out issues that determine poor program performance, including lack of adequate monitoring and enforcement and poor compliance with standards by industry.

CONCLUSIONS

In the last 17 years, large-scale food fortification initiatives have been reaching increasingly larger segments of populations in LMIC. Large-scale food fortification and biofortification should be part of other nutrition-specific and nutrition-sensitive efforts to prevent and control micronutrient deficiencies. There are remaining technical and food system challenges, especially in relation to improving coverage and quality of delivery and measuring progress of national programs.

A public health approach for preventing neural tube defects: folic acid fortification and beyond

In this paper we review the evidence basis for prevention of folic acid-sensitive neural tube defects (NTDs) through public health interventions in women of reproductive age (WRA), the proven vehicles for delivery of folic acid, and what is needed to effectively scale these, and provide a snapshot of potential innovations that require future research. Our primary focus is on the global situation affecting large-scale food fortification (LSFF) with folic acid, in particular the fortification of wheat flour and maize meal. Our overarching conclusion is that folic acid fortification is an evidence-based intervention that reduces the prevalence of NTDs, and that LSFF with folic acid is underutilized. Thus, food fortification with folic acid should be a component of most national public health strategies, in particular where folate status is insufficient and a fortifiable food vehicle, processed by a centralized industry, is consumed regularly by WRA. The evidence shows that there is still much work needed (1) to build the enabling environment and expand programs where there is currently no legislation, (2) to improve the low quality of delivery of existing programs, and (3) to measure and sustain programs by generating new coverage data and demonstrating evidence of impact in low- and middle-income countries.

The investment case for folic acid fortification in developing countries

There is compelling evidence that neural tube defects can be prevented through mandatory folic acid fortification. Why, then, is an investment case needed? At the core of the answer to this question is the notion that governments and individuals have limited resources for which there are many competing claims. An investment case compares the costs and benefits of folic acid fortification relative to alternative life-saving investments and informs estimates of the financing required for implementation. Our best estimate is that the cost per death averted through mandatory folic acid fortification is $957 and the cost per disability-adjusted life year is $14.90. Both compare favorably to recommended life-saving interventions, such as the rotavirus vaccine and insecticide-treated bed nets. Thus, there is a strong economic argument for mandatory folic acid fortification. Further improvements to these estimates will require better data on the costs of implementing fortification and on the costs of improving compliance where regulations are already in place.

Coverage and Consumption of Micronutrient Powders, Fortified Staples, and Iodized Salt Among Children Aged 6 to 23 Months in Selected Neighborhoods of Nairobi County, Kenya

BACKGROUND

Intake of micronutrient-rich foods among children aged 6 to 23 months in Nairobi is low.

OBJECTIVE

This study aimed to assess existing coverage and utilization of micronutrient powders (MNPs), fortified staples, and iodized salt among children aged 6 to 23 months prior to implementation of an MNP program.

METHODS

A cross-sectional survey among caregivers of children aged 6 to 23 months (n = 618) was implemented in 7 neighborhoods within Nairobi County, representing the implementation area of the new MNP program.

RESULTS

Results for MNP coverage and utilization showed 28.5% of all caregivers were aware of MNP, 18.5% had ever received MNP for their child, and 10.8% had fed MNP to their child in the previous 7 days. Effective coverage (ie, the child had been given the MNP at least 3 times in the previous 7 days) was 5.8%. Effective coverage of infants and young children with poor feeding practices was significantly lower as compared to those with non-poor feeding practices (coverage ratio, 0.34; confidence interval, 0.12-0.70). Most households purchased iodized salt (96.9%), fortified oil (61.0%), and fortified maize flour (93.9%). An estimated 23.9% of vitamin A requirements of children (6-23 months) were provided from fortified oil and 50.7% of iron from fortified maize flour. Most households consumed processed milk (81%).

CONCLUSION

Coverage of MNPs in the surveyed neighborhoods was low. Coverage of fortified salt, oil, and maize flour was high and provided significant amount of micronutrients to children. Processed milk has potential as a vehicle for food fortification.

Coverage and Utilization in Food Fortification Programs: Critical and Neglected Areas of Evaluation

The need for evidence to inform nutrition program design and implementation has long been recognized, yet the generation and use of evidence for program decision making has lagged. The results of the coverage surveys reported in this supplement highlight some of the strengths and areas for improvement of current population-based (i.e., staple foods and condiments) and targeted (e.g., foods for infants and young children) fortification programs. Among other topics, the results identify a few striking successful fortification programs whereby the majority of the food vehicle used is fortifiable and fortified, and coverage is equitable among those classified as vulnerable and not. Other programs have great potential based on very high use of a fortifiable food vehicle, including in most cases among the vulnerable, but that potential is not currently reached because of low compliance with fortification requirements. Programs were also identified whereby the food vehicle has limited potential to make public health contributions to micronutrient intake, given the low proportions of the population who consume the food vehicle in general or who consume the fortifiable food vehicle. Four key lessons were learned: 1) the potential for impact of food fortification depends on the appropriate choice of food fortification vehicle but also on the proportion of the food vehicle consumed that is fortifiable; 2) the design of fortification programs should be informed by the magnitude and distribution of inadequate intake and deficiency and consumption of fortifiable foods, and part of micronutrient deficiency control strategies to ensure coordination with other programs; 3) effective quality control of fortification levels in foods urgently needs strengthening, including the many governance and other policy factors that influence the capacity, resources, and commitment to do this; 4) periodic review of the assumptions related to dietary patterns that underpin food fortification is needed to ensure continual safe and impactful programs.