Developing a Global Strategy for the Control of Folate Deficiency and Folic Acid Responsive Neural Tube Defects in Low- and Middle-Income Countries (P10-107-19)

Objectives

To develop a global action plan for the control of folate deficiency and folic acid responsive neural tube defects (anencephaly and spina bifida)

Methods

• Establish a multi- and inter-disciplinary group to develop a global action plan for folate-sensitive NTD prevention • Ensure regional lab capacity exists to assess folate status applying a harmonized microbiologic assay (MBA) to measure red blood cell (RBC) folate, establishing a global network of regional laboratories coordinated by an umbrella organization • Promote improvements of folate status in women of reproductive age (WRA) in LMIC, engaging a wide variety of national and global stakeholders • Address key knowledge gaps related to the prevention of folate sensitive NTDs • Improve knowledge availability and sharing amongst global stakeholders in NTD prevention • Communicate and share the work of the Folate Task Team

Results

• A standing Folate Task Team comprised of a 2-member Secretariat, a 10-member Expert Advisory Group, 4 Ex-Officio members, and 4 “As Needed” advisors (see Fig. 1) • Identification of an initial list of 12 global stakeholders and partner organizations • Five resource laboratories have been trained at the Division of Laboratory Sciences - CDC, including labs in Vietnam, Sri Lanka, Philippines, Tanzania, and Pakistan • A training video supported by a manual and mini posters to illustrate specific activities of the assay has been produced by CDC. • A landscaping analysis has identified countries that have mandatory/voluntary food fortification practices, information on folate status in the population, burden of NTDs, and consumption patterns of fortified foods • Identification of alternative foods/food vehicles likely to be fortified to reach at-risk segments of WRA • Dissemination activities are shared at https://www.nutritionintl.org/what-we-do/nteam/folate-task-team/

Conclusions

• The estimated global prevalence of NTD-affected pregnancies is estimated to be 260,100 in 2015 and has a significant emotional and economic impact on families and society, while contributing to the loss of human potential for countries • The global action provides a clear path forward to help direct and prioritize investments, advance resource mobilization, and garner the political will to accelerate NTD prevention in LMIC

Funding Sources

The Bill & Melinda Gates Foundation.

Supporting Tables, Images and/or Graphs

Model for estimating nutrient addition contents to staple foods fortified simultaneously: Mexico and Kampala data

The objective of this work was to present a generic model for estimating fortification contents when several food vehicles are being considered simultaneously. It is based on approximating the magnitude of the nutritional inadequacy of the population (nutrient gap), the optimal use of the combination of food vehicles (fortifiable food energy, FFE), and the upper intake level to decrease the possibility that individuals with the highest combined intake of all food vehicles will exceed it. The model is intended to be used when only per capita food and micronutrient intake information, not detailed food intake data, are available. Food consumption survey data from Mexico and Kampala (Uganda) were analyzed for adult women, assuming that their intake may be similar to general per capita values. General adjustment factors for estimating the lowest and highest FFE and micronutrient intake for satisfying the requirements of other family members were calculated. These factors were used to estimate the additional effective content and the maximum allowable content, and then the recommended nutrient contents at the consumers' level were chosen on the basis of technological compatibility and cost. The method should be used in other contexts to test its validity as well as its application to nonstaple foods.

Legislative frameworks for corn flour and maize meal fortification

Corn flour and maize meal fortification can benefit the consumer when the added nutrient contents are in amounts appropriate to address nutrient gaps. Legislative instruments (standards and regulations) are needed to provide guidance to the producers and food control authorities. We reviewed a number of national standards and regulations of fortified corn flour and maize meal and identified constraints; contrary to current belief, the practice of using minimum contents or ranges of nutrients has caused confusion, misinterpretation, and conflict, and should therefore be abandoned. On the basis of the findings, a model of fortification legislation is proposed, in which the additional content and the expected average nutrient content in a final product are recommended as the main parameters for quality control and enforcement. For labeling, the average content, or one adjusted to the expected content of the product at the market, can be applied. Variation in micronutrient contents should still be checked to ensure homogeneity but with adherence to clear procedures of sampling and testing, which should be part of the standards and regulations.

Maize flour fortification in Africa: markets, feasibility, coverage, and costs

The economic feasibility of maize flour and maize meal fortification in Kenya, Uganda, and Zambia is assessed using information about the maize milling industry, households' purchases and consumption levels of maize flour, and the incremental cost and estimated price impacts of fortification. Premix costs comprise the overwhelming share of incremental fortification costs and vary by 50% in Kenya and by more than 100% across the three countries. The estimated incremental cost of maize flour fortification per metric ton varies from $3.19 in Zambia to $4.41 in Uganda. Assuming all incremental costs are passed onto the consumer, fortification in Zambia would result in at most a 0.9% increase in the price of maize flour, and would increase annual outlays of the average maize flour-consuming household by 0.2%. The increases for Kenyans and Ugandans would be even less. Although the coverage of maize flour fortification is not likely to be as high as some advocates have predicted, fortification is economically feasible, and would reduce deficiencies of multiple micronutrients, which are significant public health problems in each of these countries.

Vitamin A fortification in Uganda: comparing the feasibility, coverage, costs, and cost-effectiveness of fortifying vegetable oil and sugar

BACKGROUND

Twenty-eight percent of Ugandan preschool children suffer from vitamin A deficiency. With vitamin A supplementation covering only a third of children under 5 years of age, fortification is essential to reduce their vitamin A deficiency-related disease burden. At present, the only widely consumed food in Uganda that is fortified with vitamin A is vegetable oil.

OBJECTIVE

To compare the feasibility, coverage, costs, and cost-effectiveness of fortifying vegetable oil and sugar with vitamin A in order to assess, from a public health policy perspective, whether sugar should also be fortified.

METHODS

The 2005/6 Uganda Household Budget Survey was used to analyze households' apparent consumption levels of sugar and vegetable oil and to model the additional intake of vitamin A, assuming the sugar and oil fortification levels are those set by the Uganda Bureau of Standards.

RESULTS

The annual incremental private sector cost of vitamin fortification is US $555,668 for oil and US $2,644,765 for sugar. Assuming that oil and sugar fortification are both effective in reducing vitamin A deficiency by 30% among those who consume these foods, the estimated cost per disability-adjusted life year (DALY) averted is US $82 for sugar and US $18 for oil. Vitamin Afortification of vegetable oil is 4.6 times more cost-effective than vitamin A fortification of sugar. If sugar were to be fortified, the 17% of Ugandans who purchase sugar but do not purchase oil would become new beneficiaries of vitamin A fortification. This would increase the coverage of vitamin A-fortified foods by 31% and reduce the percentage of Ugandans without any coverage to 25%. Those most at risk for vitamin A deficiency-members of rural, poor households-would benefit disproportionately from the introduction of sugar fortification.

CONCLUSIONS

Although the lack of information on the vitamin A deficiency status of consumers of oil and sugar precludes making definitive conclusions, the increased coverage and cost per DALY averted due to sugar fortification suggests-based on World Health Organization guidelines-that the Government of Uganda should pursue sugar fortification.