Food Fortification in a Globalized World

- eBook PDF
Visit to download the full and correct content document:
https://ebooksecure.com/download/food-fortification-in-a-globalized-world-ebook-pdf/
Food Fortification in a Globalized World
Food Fortification
in a Globalized World

Edited by

M.G. Venkatesh Mannar

Richard F. Hurrell
Academic Press is an imprint of Elsevier
125 London Wall, London EC2Y 5AS, United Kingdom
525 B Street, Suite 1650, San Diego, CA 92101, United States
50 Hampshire Street, 5th Floor, Cambridge, MA 02139, United States
The Boulevard, Langford Lane, Kidlington, Oxford OX5 1GB, United Kingdom
Copyright r 2018 Elsevier Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical,
including photocopying, recording, or any information storage and retrieval system, without permission in writing from
the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our
arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be
found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as
may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden our
understanding, changes in research methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any
information, methods, compounds, or experiments described herein. In using such information or methods they should
be mindful of their own safety and the safety of others, including parties for whom they have a professional
responsibility.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for
any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any
use or operation of any methods, products, instructions, or ideas contained in the material herein.
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging-in-Publication Data
A catalog record for this book is available from the Library of Congress
ISBN: 978-0-12-802861-2

For Information on all Academic Press publications

visit our website at https://www.elsevier.com/books-and-journals

Publisher: Andre Gerhard Wolff

Acquisition Editor: Megan R. Ball
Editorial Project Manager: Billie Jean Fernandez
Production Project Manager: Omer Mukthar
Cover Designer: Mark Rogers
Typeset by MPS Limited, Chennai, India
Contents

List of Contributors xv 2.3 Conclusions 24

Foreword xv ii
Refe re nces 25
Further Reading 28

3. Developing National Strategies to

Section I Prevent and Control Micronutrient
Need and Approach 1 Deficiency: The Role of Food
Fortification
1. Food Fortification: Past Experience,
Mduduzi N.N. Mbuya and Lynnetce M. Neufeld
Current Status, and Potential for
3.1 Introduction: Towards Country Led
Globalization
Strategies for Prevention and Control
M.G. Venkatesh Mannar and Richard F. Hurrell of Micronutrient Deficiencies 29
3.2 Food F o rtif ic ation and Nutrient Intakes:
1.1 Background 3
The E v i den ce 30
'1.2 Early Successes Wi th Food Fortification 5
3.2.1 Large Scale Food Fortificalion
- and
1.3 Types of Fortification 6
Heallh Outcomes 31
1.4 Se lec tio n of Vehicles 7
3.2.2 LSFF and N u t ri ent Intakes 31
1.5 Biofortification 8
1.6 Current Situation, Issues and Challenges 9 3.2.3 Targeted Fortification, Nutrient

1.7 Concluding Th o ughts 10 Intakes. and Health Outcomes 31

References 11 3.2.4 Food Fortification and Risk of
Adverse Effects 32
3.3 Implications for National Fortification

2. Prevalence, Causes, and Consequences Plans 32

3.4 Food Fortification and Other
of Micronutrient Deficiencies. The Gap
Approaches to Control of Micronutrient
Between Need and Action Deficiencies 33
Jan Drlrnton-Hjlf 3.5 Evidence and Decision Making:
A Need for Data-Driven Coo rdinati o n 34
2.1 Introduction 13 3.6 Nutrition Actions to Enabl e and
2.2 The Gap in Micronutrient Intakes at Support Food Fortification 35
Popul ation level and the Resultant 3.0.1 Nutrition Actions.: Everybody's
Defi ciency Outcomes Being Addressed 13 Business. and Nobody's
2.2.1 Iron Deficiency and Anemia 15 Responsibility 35
2.2.2 todine 17 3.6.2 Nutrition Actiolls.: Calling All Hands
2.2.3 Folate and Neu ra l Tube Defects on Deck 36
INTDs) 18 3.0.3 Nutrition Actions: Asking the Right
2.2.4 Vitdmin A Deficiency 19 Questions 37
2.2.5 Zinc 21 3.7 Co ncl usi on 38
2.2.6 Other Micronutrients 22 References 38

v
vi Contents.

Section I I 5.7 Th e Way Forward for National

Mandated Fortification Programs 60
Recommendations and Guidance 41 Acknowledgments 61
References 61
4. Using Dietary Reference Values to F u r th er Reading 62

Define Fortification Levels for

National Prog rams 6. Market-Driven Fortification
Lindsay H. Allen Petra Klassen-Wigger and Denis V Barclay
4.1 Importance of Food Fortification 43
6.1 Context for the Food Industry 63
4.2 Application of Recommended Intake
6.2 Key Considerations 63
Values 43
6.21 Documen ted Evidence of M D 63
4.2.1 Average Requirements and Upper
6.2.2 Nutritional Relevance of
Levels 43
Markel-driven Fortification Vectors 63
4.2.2 Recommended Intakes and Adequate
6.2.3 Fortification level 64
Intakes 44
6.2.4 Safety 64
4.3 Calculating the Prevalence of Inadequate
6.2 5 Cost of Fortification and Affordability 65
Intakes 44
6.2.6 Communication-Nutrition and
4.4 Nutrient Data Bases 45
4.5 Correcting for Day-tn-day Variance in Health Claim, and Regulations 65

Intake 45 6.2.7 Organoleptic Impact and Stability 65

4.6 Bioavailability Factors 45 6.28 Bioavailability Versus Organoleptic
4.7 Exceeding Upper levels of Intake 46 Quality: Exam ple of Iron 66
4.8 Using Soft.ware to Plan Fortification Based 6.2.9 Evaluation of Market-driven
on Dietary Reference Intakes 46 Fortification Interventions 66
4.9 Alternative Approaches to Setting 6.3 Solutions and Outlook 66
Fortification Levels 47 6.3.1 Development of Fortificants
References 49
With Improved Bioavailability and
Organoleptic Properties 66
6.3.2 Bio(ortiiical ion 66
Section I II 6.33 Public-Priv.le Partnerships 67
Delivery Methods 51 References 67
Further Reading 67

5. National Mandated Food

Fortification Programs 7. Biofortification: An Agricultural Tool
Greg S. Garrett to Address Mineral and Vitamin
Deficiencies
5.1 Introduction: The Rationale for
National Food Fortification Programs 53 How.lrth E. Bou;s
5.2 A Snapshot of Na tional Food Fortification
Programs Around the World 53 7.1 Agr iculture and Mineral and ViLamin
5.3 Selecting an Approach: Mandatory Deficiencies in Developing Countries 69
Fortification/ Voluntary Fortification, 7.2 Justification for Biofortification 70
and Public Distribution of Fortified Foods 54 7.2.1 Comparative Advantages 70
5.3.1 Mandatory Fortification 54 7.2.2 Cost-Effeeliveness 70

5.3.2 Voluntary Fortification 56 7.3 Nutri tional Bioavailability and Efficacy

E v idenc e 71
5.3.3 Fortified Foods as a Component
of Public Distribution Systems 57 7.3.1 Iron Crops 71
5.4 Actors in National Food Fortification 57 7.3.2 Vitamin A Crops 71
5.5 National Food Fortification Alliances 57 7.3.3 Zinc Crops 72
5.6 Frameworks for National Mandated 7.3.4 Future Areas of Investigation 72
Fortification Programs 58 7.4 Crop Development 72
5.0.1 The Build/Expand Stage 58 7.4.1 Transgenic Approaches 73
5.0.2 The Improve Stage 59 7.4.2 International Nurseries/Global Testing 73
5.0.3 The Measure/Sustain Stage 60 7.43 low-Co,t, High Throughput Melhods 74
 Contents vii

7.4.4 Relea ses of Biofortified Crops 74 9.2.2 Stages of Financing of National

7.5 De livery Experiences in Target Counties 74 Foud Fortification Programs 94
7.5.1 Vegetatively Propaga ted Crops 75 9.2.3 Level of Fi nancing Required 95
7.5.2 Cassava in Nigeria and DR Congo 75 9.2.4 Sources of Financing 95
7.5.3 Self-Poll inoted Crops 75 9.2.5 Affordability of Fortification 95
7.5.4 Beans in Rwanda and DR Congo 76 9.3 Enhancing the Sustainability of Food
7.5.5 Rice in Bangladesh 76 Fortifica tion 96
7.5.6 Hybrid Crops 76 9.3.1 Ecology 96
7.5.7 Maize in Zambia 77 9.3.2 Ec onom ic 97
7.5.8 Pearl Millet in India 77 9.3.3 Pol itic a l 97
7.5.9 L essons Learned From Delivery 77 9.3.4 C u ltura l 98
7.6 Building Blocks for Global D elivery 77 9.4 Concl us i on 98
7.6.1 StandJrds and Regulatory 78 References 99

7.6.2 Multi latera l In stitutions 78

7.6.3 Private Sector 78
7.6.4 NCOs 78 10. Creatin g Consumer Demand and
7.6.5 Moving Bey ond Target Countries to Driving Appropriate Utilization of
Partnership Country Strategies 79 Fortified Foods
7.7 A Fut ur e Vision To Drive and Guide
Mai ns treaming 79 Marti j. van Liere and Susan Shulman
References 79
10.1 Introduction 101
Annex 1: Evidence on the Bioavailability,
10.2 Supply Factors Which Play all
Efficacy, and Effectivenes5 of Biofortified
Important Ro le in Dr iving Demand 102
Foods 81
10.2.1 Affordability and Value-for-
Mo ney 102
10.2.2 Availability as a Driver of
Section IV
D em and 104
Technical and Business 10.2.3 Perceived Q ual i ty and Product
Considerations 83 Attributes 106
10.2.4 Packilging as Means to

8. Grain Fortification Processes, Com m unicate 1 06

10.3 Demand Factors for Fortified Foods 107
Technologies, and Implementation
10.3.1 From Awareness to Consumer
Criteria
Relevance and Preference 107
Sarah Zimmerman and Scott}. Montgomery 1 0.3.2 From First Tr ial to Regular Use 108
10.4 Compliance and Effective Use 108
8.1 Grain Fortification Processes, 10.5 Conclusions and Recommendations 110
Technologies, and Implementation Criteria 85 Refe r ences 110
8.l.1 Introduction 85 Further Reading 112
8.2 Processes 86
8.3 Technologies 87
8.4 Implementation Criteria 87
11. The Importance of Public-P rivate
8.5 Conclusion 90
Acknowledgments 90 Collaboration in Food Fortification
References 91 Programs
Further Reading 92
Greg S. Garrett, Caroline Manus and Andreas
Bleuthner
9. Financing and Sustainability of
11.1 Introduction 113
Food Fort ification 11.2 Why Collaborotion Betwee n th e

Luc Laviolette Private and Publ ic Sector is Critical

for Success 114
9.1 Intr od uct i on 93 1 1.3 Frameworks, Tools, and Processes for
9.2 F in ancing of Food Fortification 93 Effective Public-Private Collaboration 114
9.2.1 Food Fo rt ification is a Good 11.4 Example5 of Public-Private
Investment 93 Col labo ra tion 115
viii Contents

11.4.1 National Fortification Alliances 115 13.5.2 Delivery Options for Fortified
11.5 Gaps and Opportunities fo r I m p roved Rice 138
Public-Private Collaboration 116 13.6 Conclusion 140
11.5.1 Human Capacity 118 References 140
11.5.2 Setting Legislation and Standards
for Impact 11 S
14. Salt
11.6 Regulatory Monitoring 116
11.7 Conclusion 116 M.G. Venkatesh M.lnnar
References 119
Further Reading 119 14.1 Salt as a Carrier of Nutrients 143
14.2 lodization of Salt 143
14.2.1 Consolidation and
Section V Modernization of the Salt
Industry 144
Fortification Vehicles 1 21
14.2.2 Monitoring and Evaluation 145
14.2.3 International Support 145
12. Wheat and Maize Flour Fortification 14.3 Key Determinants to Achieve
Universal Salt lodization 145
Helena Pachon
14.3.1 Making Salt lodization a Global
12.1 I ntroduction 123 Industry Norm 145
12.2 Fortification Industry Structure for 14.3.2 Sustained Public Education
Wheat Flour and Maize Flour 123
and Social Mobilization 147
12.3 Global G uide l ines for Fortification 124
14.3.3 Supporting Small S al t Producers 147
12.4 COlintries With Ma n dato ry and
14.3.4 Engagin g the Processed Food
Voluntary Legisl ation 124
Industry 148
12.5 Nutrients, Fortificants, and levels
Included in Legislation/Standards 124 1 4 .3 . 5 Monitoring and Adjusting Iodine

1 2.6 Coverage and Compliance in Intakes 148

Mandato r y and Volu nt ar y 14.3.6 Double Forlified Sail 148

Countries 126 14.4 Mul tiple Fortification of Salt 149
12.7 Health Impact From Flo ur 1 4.5 Scale Up of DFS 150
Fortification 127 14.6 Cost. of Multiple Fortification 150
12.8 Way Fo rward to Accelerate the 14.7 Conclusions 150
Coverage and Impact of Flour References 151
F o rt i fi catio n 127 Further Reading 151
Acknowledgements 128
References 128
15. Condiments and Sauces

Vis;t.h Chavasit and juntima Photi

13. Rice Fortification
15.1 Introduction 153
Saskia de Pee, Becky L. Tsang,
15.2 Forms of Condiments 153
Sarah Zimmerman and Scali Montgomery
15.3 Fortification Process 154
13.1 Introduction to Ri ce Fortification 131 15.3.1 Solid Condiments 154
13.2 History of Rice Fortification 132 15.3.2 Semi-Solid Condiments 1.\5
13.3 C hoi c e of Tech nolog ies to Produce 15.3.3 Liquid Condiments 155
Fortified Rice Kernels 133 15.4 Challenges 156
13.3.1 Considering Rice Fortification 15.5 Potential 156
Tec hnologies From a Cons u m er References 15 6
Perspective 133
13.3.2 Considering Rice Fortification
16. Bouillon Cubes
Technologies.From a
Manufacturing Perspective 135 Diego Moretti, Richard F. Hurrell and
13.4 Which Micronutrients to Add to Rice 136 Colin I. Cercamondi
13.5 Introducing Rice Fortification- How
16.1 Bouillon Cubes 159
and Where? 136
16.2 Estimated Use a nd Consumption
13.5.1 Rice Landscape Analysis 138
of Bouill o n Cubes 159
 Contents j"

16.3 Current Fortification Practices 1 60 19. Breakfast Cereals

16.3.1 Iodine 160
Kathryn Wiemer
16.3.2 I ron 161
16.33 Future Research Direc tio n s 163 19.1 Introduction 163
16.34 Other Fortificants Added to 19.1.1 Pol icy and Regulatory H istory 183
Bouillon Cubes 164 19.2 Ce real F orti fication Co nsi d e rations 164
16.4 Conclusions a n d Outlook 164 19 . 2.1 Sc ient ific 184
Referenc e s 164 19.2.2 Technical and Processing
Met hod 186
19.3 Impact of Cereal Fortification on
17. Micronutrient Fortif ication of Edible
Nutrient Intakes 169
Oils 19.4 Future Considerations 169

Levente Liiszl6 Oiosady and References 190

Kiruba Krishnaswamy

17. 1 Introduction 167 Section VI

17.2 Rationale for Fortification of Edible
Oils 167
Nutrient Wise Review of Evidence
17.3 Necessity for Fortification of Oil With and Safety of Fortification
Micronutrients 166
17.4 Technology for Edible Oil Fortification 1 70
17.5 Postprocessing Requirements in O il
20. Efficacy and Safety of Iron
Fo rtifi catio n 170 Fortif ication
17.5.1 Quality Control 171
Richard F. Hurrell
17.5.2 Stabi lity of Vitamins 171
17.5.3 Safety and Tox i city 20.1 Iron Fortification Com pou n ds With

Considerations 172 Confirmed Efficacy 196

17.6 Standards and Regulati ons 172 2 0.1. 1 D efin i ng the I ro n Fortification
17.6.1 Quality Standards 172 Level 196

1 7. 6. 2 Mo nitoring and Enforcement 172 20.1.2 Ascorbic Acid 197

17.6.3 Commerc ia lly Available 20.1.3 Ferrous Sulfate 197

Premix for Oil Fortification 172 20.1.4 Ferro us G[ uconate 198
17.7 Biologic al Efficacy of Fortified Oil 173 20.1.5 Ferrous Fumarate 198
17.8 Curr ent Status of Micronutrient 2 0. 1. 6 Ferric Pyrophosphate 198
Fortification of Edible Oils 173 20.1.7 Elect rolyt ic Iron 199
17.9 Conclusion 173 20.1.B Sodium Iron
Refe re nces 174 Ethylenediaillinetetraacetic Acid 200
Further Reading 174
20.1.9 Ferro us B isgl yci nate 201
20.2 Technologically Modified Iro n
Compounds With Confirm e d Efficacy 201
18. Milk a nd Dairy Products
20.2.1 Encapsulated Ferrous Sulfate 201
Daniel Lopez de Romaiia, 20.2.2 E nca psul a ted Ferrous Fumarate 202
Mc1(HleJ Olivares and Fernando Pizarro 20.2.3 Micronized Di s pe rsi ble Ferric

18.1 Introduction 175 Py roph osp hate SunAclive Fe 202

18.2 History 175 20.3 Oth er Potential ly Useful Compounds 202

18.3 Curren t Practices, Micro n utri ents 20.3.1 Ferric Ammonium Citrate 202
Added, and Comp ounds Used 1 76 20.3.2 Ferrous Lactate 203
18.4 Vehicle Con sumpt ion Patterns 177 20.3.3 Ferric Orthophosphate 203
18.5 Technologies 177 20.3.4 Ferrous Succinate 203
18.0 Pote ntial for Impact 179 20.4 Cu rren t De v elopme n ts in Iron
18.7 Challenges 160 Fortifica tion 203
Refere nces 160 20.4. 1 Phytase 203
" Contenls

20.4.2 Nano I ron 203 22.3 N utriti o nal Goitrogens That Influence
20.4.3 Asp iro n 203 Iodine Efficacy 224
20.5 Suggested Iron Compounds for 22.4 Assessment of Iodine Stat us in
Different Food Vehicles 203 Populations 225
20.5.1 Cereal Fioursl Bread and Pasta 203 22.5 The Safety of Iodized Salt Progra ms

20.5.2 Rice 204 and t h e Effects of Iodine Exce ss 225

22.6 Conclusions 228
20.5.3 Salt 204
References 228
20.5.4 Soy Sauce and Fish Sauce 204
Further Reading 230
20.5.5 Bouillon Cubes and Spice
Mixes 205
20.5.6 Mi Ik Products 205 23. Global Status of Folic Acid
20.S.7 Beverages 205 Fortification - Progress and Gaps
20.5.8 Cereal-Based Complementary
Creg S. Carrett and Lynn B. Bailey
Foods 205
20.5.9 Micronutrient Powders 205 23.1 I ntroduc t io n 231
20.5.10 Chocolate Drink Powders 205 23.2 Global Status of Folic Acid
20.5.11 Breakfast Cereals 205 F or tificati on - Prog ress and G aps 232
20.6 Potential Health Risks of Iron 23.3 Research Gaps, Other Potential
Fortification 205 Fortifiable Vehicles and I nnova t ions 235
20.6.1 Infectious Disease 205 23.4 Sum m ary and Conclusion 237

20.6.2 Iron Overloa d 206 Acknowledgments 237

20.6.3 Cardiovascular Disease 206

Competing Interests 237
References 237
20.6.4 Diabetes Type 2 207
Further Reading 239
20.6.5 Cancer 207
20.7 Balance Between Benefit and Risk 207
References 207
24. Assessing all the Ev idence for
Risks and Benefits W ith Folic Acid
21. Z inc Fortif ication Fortificat ion and Supplementation
Jai K. Das, Raja S. Khan and Zulfiqar A. Bhutta Irwin H. Rosenberg and Jacob Selhub
21.1 Introduction 213 24.1 Folic Add Fortification of Grain
21.2 Zin c Bioavailability and Metabolism 213 Products 241
21.3 Measuring Zinc Status and Deficiency 215 24.2 Investigation of Effects o f High
21.4 Health Risks and Benefits of Zinc 215 Folic Acid Intakes 241
21.5 Zinc Fo rtificants 216 24,3 Vitamin B12- Folic Acid Intervention 242
21.6 Nati ve Zinc and Zinc-Fortified Foods 216 24.4 Unmetabolized F oli c Acid and Folic
21.7 Safety and Efficacy of Fortification 217 Acid Excess 243
21.8 Concl u si on s 218 24.5 Evidence of I n cr ea sed Vulnerability
Referenc es 218 to Folic Acid Excess in Po pulations
With Genetic Polymorphisrns 244
24.6 Concluding Remarks 245
22. Efficacy and Safety of Iodine
References 245
Fortification

Michael B. Z;mmerm�nn
25. Nutrient-W ise Review of Evidence
22.1 Introduction: The Iodine Deficiency
and Safety of Fortification: V i tamin A
Disorders 221
22.1.1 Diffuse Goiter and Mutinodular Sh erry A. Tanumihc:1fdjo
Toxic Goiter 221
25.1 Chemical Forms of Fortificants 247
22.1.2 Neurocognitive Im pJirm ent 221
25.2 Efficacy Studies 247
22.2 Efficacy of Iodized Salt: National
25.3 Effectiveness Studies 248
and Global Iodine Status 223
25.4 Cost-Effectiveness Analyses 248
 Contents xi

25.5 links With Other Nutrients 249 27.2.6 Experience With Calcium
25.6 Foods T hat Ar e Being Fortified 249 Fortification 2 69
25.7 Biofortification of Staple Foods With 27.2.7 Nutritional Benefits of Calciurn
Provitamin A Carotenoids 249 Fortification 269
25.8 Concerns and Limitations 250
27.2.8 Safety of Calciurn Fortification 270
25.8.1 Quality of Vegetable Oil and
27.2.9 Conclusions 270
Monitoring 250 References 270
25.8.2 Matrix of the Staple Versus the
Forti fi cant 250
25.8.3 The Potenti(ll for Excessive Secti o n VII
Intakes 250
Program Performance
References 251
Measurement and Improvement

26. Efficacy and Safety of Vitamin B12 28. Program Performance and
Fortification Synthesis of Monitoring

Lindsay H. Allen Information for Food

Fortification
26.1 Prevalence of Vitamin B12 D eficien cy 255
26.2 Why Vitamin B12 Status Is Important 255 Laird f. Ruth, Svenja Jungjohalln,
26.3 Cofortification of Vitamin B12 and Folic Helella Pachan and Mary Serdula
Acid 256
28.1 Introduction 275
26.4 Diagnosis of Deficiency and Depletion 257
28.2 Overview of Pr incipal Co m pon ents
26.5 Requi r e m ents, Bioavailability, and
of An M&E System for Food
Safety 257
Fortification 276
26.6 Expert Con s en sus on Recommended
28.2.1 Regulatory Monitoring 276
Vitamin B12 Fortification 258
28.2.2 Household/Individual
26.7 Experience With Vitam in B12
Fortification 258 Monitoring and Evaluation 277
26.8 Conclusions 259 28.3 Overall Monitoring and Evaluation

References 260 Frame w ork 278

28.3.1 Step 1: En gage Stake h ol de r s 279
28.3.2 Step 2: Describe the Program 279

27. Vitamin D and Calcium 28.3.3 Step 3: Focus the Design for
Food Fortification Monitoring 279
Kevin D. Cashman and Albert Flynn
28.3.4 Step 4: Gather Credible
27.1 Vitamin 0 263 Evidence 280

27.1.1 Introduction 263 28.3.5 Step 5: Justify Conclusions 280

27.1.2 Deficiency and Insufficiency 263 28.3 . 6 Step 6: Ensure Use of Results

27.1.3 Recommended Intakes 264 (lnd Sh(lre Lessons 281

27.1.4 Current Po p u l at i ons Intakes of 28.4 Conclusion 281

Acknowledgments 281
Vitamin 0 and the Case for
References 281
Food Fortifi<:ation 264
27.1.5 Fortification of Foods With
Vitamin D, Which Forms and 29. Regulatory Monitoring of
Which Foods? 266 Mandatory Fortification
27.1 6 Safety of Vi ta m in 0 Fortification 267
Programs
.

27.1.7 Conclusions 267

27.2 Calcium 267 Laura A. Rowe, Corey L. Luthringer and
27.2.1 Introduction 267 Greg S. Garrett
27.2.2 Recommended Intakes 268
29.1 I nt roducti o n 283
27.2.3 Deficiency 268
29.2 Background to Re gulato ry Mo n itor ing
27.2.4 Food Sources of Calcium 268 of Fortified Foods 284
27.2.5 Calcium Fortificants 268
xii Conlents

2 9 .3 Common Cha llenges in 30.5 Fortified Food Intake 294

I m p l e m e nti ng Effective Regulatory 30.6 Mic r o nu tr ie nt I nta ke F r o m F ort ifi ed
Monitoring 285 Food 294
29.4 Iden ti fi ed Good Practi ces Which 30.7 Way F orward to Accel era te
Can Help CQuntries Overcome Consumption Monitoring of Fortified
Barriers 285 Food 295
29.4.1 Simpl ify the Process of Acknowledgments 296
Co mp l i a nce Data Collection D i scl a i me r 296

and Management 2 86 Referen ces 296

29.4.2 Include Fortification i n Exi st i ng

Food Safety Ma n da tes and 31. Economics of Food Fo rtification
InspectIon Forrns 287
Susan Horton and M.e. Venkatesh Mclnnar
29.4.3 I de nti fy and Implement Effective
Incentive and Pe n a l ty Schemes 3 1 . 1 Economic Costs o f Fo rtification 299
fo r I n dustry 287 3 1 .2 Cost-Effectiveness and Cost-Benefit 301
29.4.4 I ncrease the Ro l e of Civil 3 1 .3 Conclusions 303
Soc i ety a n d Cons u me r G rou ps 287 Refe re n c es 303
29.4.5 Establish Clear R o l es ,
Respons i b i l ities/ a n d Wor k i n g
32. I m pact Evaluation of Food
Environm ents for Government
Fortification Programs: Review
I nspectors 287
29.4.6 Ensure a Trained Cadre of of Methodological Approaches
I nspectors 288 Used and Opportunities to
29.4.7 E l evate the P ub l i c Profile of Strengthen Them
Fortificcltion to Motivate
Lynnette M. Neufeld and Valerie M. Friesen
Government to Imp rove
Comp l i a nce 288 32.1 Introduction 305
29.5 Po licy Recommendations and 32.2 Brief Overview of Fi n d in gs From
I m pl i catio ns 289 F ortificati o n Prog ra m Impact
Refere n ces 289 Eva l uat i o n s 306
Further Re ad i n g 290 32.3 Evaluation Designs Used to
Assess Impact o f Food Fortificati o n
Programs 309
30. Consu mption Monitoring: 32.4 B e yo n d I m pact: Assessing Program
Coverage, Provision, Pathways and Evaluability 312
32.5 I m p lications for I m p ro vi n g Food
and Util ization
Fortification Pro g ra m Evaluations 312
Helena Pach6n and Omar Dary 32.6 Conclusions 313
References 314
3 0 . 1 Introduction 29 1
30 . 2 General Conside rations 291
3 0 . 2 . 1 Ter m i no l ogy 291
30.2 .2 Assumptions 292 Sect i o n VI I I
3 0 . 2 . 3 When to I n i t ia te Consumption N ational Program Case Studies
Mo n i to ri ng 292
and Lessons Learned
30.2.4 Relationship With I m pact
Evaluations 292
30.2.5 Periodicity of Co n su mpti o n 33. National Program Case Studies and
M o n i tori ng/Food Consumption Lessons Learned: South Africa
Patterns 292
Philip Randall
3 0 . 2 . 6 Maximizing Resou rces 292
30.3 Fortified Food Coverage 293 33.1 N a ti onal Fo rt ificati o n A l l i a n ce 320
30.4 Micron utr ie nt Provision 3 3 . 1.1 Impact Evaluation 323
(or Additional Micronutrient 33.2 lessons learnt 324
Conlent per U n i t We ight) From References 324
Fortified Food 293 Further Reading 324
 Contents xiii

34. Food Fortification in Senegal : 37. N atio n al Pro g ram Case Studies and
A Case Study and Lessons Learned lessons Learned From Bangladesh

K.l Abdou/aye and Caroline Manus Basanta Kumar Kar

34.1 Introduction 327 37. 1 I nt ro d ucti on 349

34.2 Food Fortification Program (FFP) in 37.2 Buil di ng a Shared V i si o n on the Need
Senegal 327 a.nd Henefits of Vitam i n A Fortifica.tion 349
34.2.1 Ce l l u l e d e Lutte contre 1 3 37.3 Phase 1 : Strategizing Ma nd ato ry
Malnutrition (CLM): An E n a bl ing Fortification 350

Environment ior Food 37.4 Phase 2: Advocacy and Enactment

o f the Law 350
Fortiflcation i n Senegal 327
37.5 Phase 3: Man ag i ng and Miti gati ng
34.2 . 2 Achievements o i the F F P 328
Post Enactment Challenges 351
34.3 Progra m Chal l e n ge s 329
37.6 Phase 4: En force m ent of the law and
34.4 lessons learned 329
I m p lementation of the Program 351
34.5 Conclusion 331
37.7 Key D rive rs of Success 352
Refe re nces 331
37.8 lessons learned 352
Fu rther Rea d i ng 352
35. E q u ity of Impact on Anemia and
I ron Status of the Food Fortification
S ecti o n IX
Program of Costa Rica
Business Case Studies
Reyna/do Martorell

35.1 Int rodu ction 333 38. Business Considerations for

35.2 Program De scription 334
Food Fortification: Carg i ll
35.3 Results 334
I n dia Experience With
35.4 Discussion 336
35.4.1 Attri bution of Causal ity 336 Oil Fortification
35.4.2 Missed Opport u n ities i n Siraj A. Chaudhry
E va lu ati o n 338
38.1 Introduction 357
3 5 .4.3 Exp l a i ning the Equity of the
38.2 Fortification: A Ste p i n the Rig h t
I m pact on Anemia 338
D i recti o n 358
3 5 .4.4 Lessons From Costa Rica for
38.3 Oil Fortification - A Viable Means to
Effectiveness Evaluations 339
Address Vitamin A and D Deficiencies 358
Refe re nc es 339
38.4 India Oil Consum p ti o n Facts 358
F u rth e r Rea ding 340
38.5 lessons From Business: Ca rgi ll
I nd i a Pri v ate l i mited : Ex pe rie nce

36. Food Fortification in Canada With Fortifying E d i b le Oil 359

38.6 The Vision 359
Anthea Chrisloforou, Sheida Norsen 38.7 Technology 360
and Mary L'Abbe 38.8 From Co n c ept to I m p lementation 360
38.9 Fi n an cial Implications 361
36.1 Mandatory Food F o rti fication in
38 . 1 0 B ran ding and Mar keting 361
Canada 341
38 . 1 1 Re ach i ng the Hottom of the Pyram id 361
36 . 1 .1 The Case of Vitamin 0 :
38.12 Building 011 the Momentum 361
A Publ ic Health Success Story? 342 Referen c es 362
36.2 D i scr etionary Fortification i n Canada 343 Further Reading 362
36.2 1 Policy Evolution 343
36.2 . 2 Prevalence o f Dis.cretionary
Fortification in Canada 344 39. Micronutrient Fortification
36.2.3 N u trition and Health I mp l ication of B o u illon C u bes in Centra l and
of Discreti onary Fortification i n West Africa
Canada 344
Petra Klassell-Wigger; Maarten Ceraets"
36.3 Conc l u sio n s 346
Marie C. Messier; Patrick Detzel,
Refe ren ces 346
Henri P. Lenoble and Denis V. Barclay
xiv Contents

39.1 I ntroductio n 363 S ecti o n X

39.2 I m p lementation of Iron Fortification
of Bouillon 364
Future Trends and Strategies
39.3 Nutritional Relevancy 364
39.4 Bioavailability 365 40. Future Trends and Strategies i n
39.5 Stability/Shelf life Test 367
Food Fortification
39.6 Safety 367
39.7 Tech n i ca l Req uirement and M.G. Venkates" Manna" Greg S.
Ch a l l enges 368 Garre ll and Richard F. Hurrell
39.7.1 Selection of the Iron
40.1 The Way Forward 379
Compound
Fo rtification 368
40.2 Conclusion 381
3 9 . 7.2 Homogeneity 369 References 381
39.7.3 Qual ity Assurance 369 Further Reading 381
39.8 Communication of N utritional
Benefits to Consumers 369
39.8.1 Understanding Lower-Income Index 3 83

Consumers 369
39.9 Business Impad 370
39.10 Future Chal l en ges 370
39. 1 0. 1 Replication and Sustainability 371
References 371
List of Contributors
Ka Abdoulaye, Government of Senegal, Dakar, Senegal
Lindsay H. Allen, USDA, ARS Western Human
Nutrition Research Center, Davis, CA, United States
Lynn B. Bailey, University of Georgia, Athens, GA,
United States
Denis V. Barclay, (Retired) Nestec SA, Vevey,
Switzerland
Zulfiqar A. Bhutta, Aga Khan University, Karachi,
Pakistan; The Hospital for Sick Children, Toronto,
ON, Canada
Andreas Bleuthner, University of Mannheim,
Mannheim, Germany
Howarth E. Bouis, Interim CEO, HarvestPlus,
International Food Policy Research Institute,
Washington, DC, United States
Kevin D. Cashman, University College Cork, Cork,
Ireland
Colin I. Cercamondi, Institute of Food Nutrition and
Health, ETH Zürich, Switzerland
Siraj A. Chaudhry, Cargill India Pvt Ltd, Gurgaon,
Haryana, India
Visith Chavasit, Institute of Nutrition, Mahidol
University, Salaya, Thailand
Anthea Christoforou, University of Toronto, Toronto,
ON, Canada
Ian Darnton-Hill, University of Sydney, Sydney, NSW,
Australia; Tufts University, Boston, MA, United States
Omar Dary, US Agency for International Development,
Washington, DC, United States
Jai K. Das, Aga Khan University, Karachi, Pakistan
Saskia de Pee, UN World Food Programme, Rome,
Italy; Tufts University, Boston, MA, United States;
Wageningen University, Wageningen, The Netherlands
Patrick Detzel, Nestlé Research Center, Lausanne,
Switzerland
Levente László Diosady, University of Toronto,
Toronto, ON, Canada
Albert Flynn, University College Cork, Cork, Ireland
Valerie M. Friesen, Global Alliance for Improved
Nutrition (GAIN), Geneva, Switzerland
Greg S. Garrett, Global Alliance for Improved Nutrition
(GAIN), Geneva, Switzerland
Maarten Geraets, Nestlé India Ltd Nestle House,
Gurgaon, Haryana, India
Susan Horton, University of Waterloo, Waterloo, ON,
Canada
Richard F. Hurrell, Swiss Federal Institute of
Technology, Zurich, Switzerland; Institute of Food
Nutrition and Health, ETH Zürich, Switzerland
Svenja Jungjohann, Global Alliance for Improved
Nutrition, Geneva, Switzerland
Basanta Kumar Kar, Project Concern International
(PCI), New Delhi, India
Raja S. Khan, Aga Khan University, Karachi, Pakistan
Petra Klassen-Wigger, Nestlé Research Center,
Lausanne, Switzerland
Kiruba Krishnaswamy, University of Toronto, Toronto,
ON, Canada
Luc Laviolette, World Bank, Washington, DC, United
States
Henri P. Lenoble, Nestec SA, Vevey, Switzerland
Daniel López de Romaña, Nutrition International,
Ottawa, ON, Canada
Corey L. Luthringer, Global Alliance for Improved
Nutrition, Geneva, Switzerland
Mary L’Abbé, University of Toronto, Toronto, ON,
Canada
M.G. Venkatesh Mannar, University of Toronto,
Toronto, ON, Canada
Caroline Manus, Global Alliance for Improved
Nutrition (GAIN), Geneva, Switzerland; Government
of Senegal, Dakar, Senegal
Reynaldo Martorell, Emory University, Atlanta, GA,
United States
Mduduzi N.N. Mbuya, Global Alliance for Improved
Nutrition (GAIN), Geneva, Switzerland
xv
xvi List of Contributors
Marie C. Messier, Nestlé Central West Africa Ltd,
Accra, Ghana
Scott J. Montgomery, Food Fortification Initiative,
Atlanta, GA, United States
Diego Moretti, Institute of Food Nutrition and Health,
ETH Zürich, Switzerland
Lynnette M. Neufeld, Global Alliance for Improved
Nutrition (GAIN), Geneva, Switzerland
Sheida Norsen, University of Toronto, Toronto, ON,
Canada
Manuel Olivares, University of Chile, Santiago, Chile
Helena Pachón, Food Fortification Initiative & Emory
University, Atlanta, GA, United States
Juntima Photi, Institute of Nutrition, Mahidol
University, Salaya, Thailand
Fernando Pizarro, University of Chile, Santiago, Chile
Philip Randall, P Cubed, Silverton, South Africa
Irwin H. Rosenberg, Tufts University, Boston, MA,
United States
Laura A. Rowe, Project Healthy Children, Cambridge,
MA, United States
Laird J. Ruth, Centers for Disease Control and
Prevention, Atlanta, GA, United States
Jacob Selhub, Tufts University, Boston, MA, United
States
Mary Serdula, Centers for Disease Control and
Prevention, Atlanta, GA, United States
Susan Shulman, Independent Consultant, Philadelphia,
PA, United States
Sherry A. Tanumihardjo, University of Wisconsin-
Madison, Madison, WI, United States
Becky L. Tsang, Food Fortification Initiative, Atlanta,
GA, United States
Marti J. van Liere, Independent Consultant, Geneva,
Switzerland
Kathryn Wiemer, General Mills, Inc., Minneapolis,
MN, United States
Sarah Zimmerman, Food Fortification Initiative,
Atlanta, GA, United States
Michael B. Zimmermann, Swiss Federal Institute of
Technology (ETH) Zürich, Zürich, Switzerland
Foreword

Prior to joining Global Alliance for Improved Nutrition (GAIN) in 2016, I assumed that the large-scale fortification of
food was a given, even in low- and middle-income countries. How wrong I was. While huge advances have been made
over the past 20 or so years in establishing and strengthening national fortification programs, still only a small fraction
of the staple foods that are fortifiable are actually fortified. Moreover, not all of the staple foods that are fortified are
fortified to the right level and in the right way. And not enough people are consuming enough fortified staples to close
micronutrient gaps. This is clearly an agenda that is unfinished.
These are just some of the issues explored in this comprehensive book, written by people who have been at the abso-
lute forefront of expanding the reach of fortified staples. They outline the challenges of fortifying staples and the solu-
tions that have been developed to overcome them. The challenges are technical (e.g., can staples be fortified with more
than one micronutrient at a time?), logistical (e.g., how to fortify staples when there is no large scale milling facilities
and how to safely store the micronutrient premix that is added to the staple?), policy-related (e.g., how to create a tariff
regime that encourages rather than penalizes firms from fortifying staples?), research-related (e.g., how do you fortify
rice grains with micronutrients?), and political (e.g., addressing the issue of potential conflicts of interest when working
with businesses and the sensitivities around perceived trade-offs between fortification and other strategies to reduce
micronutrient malnutrition). And yet there are solutions to all of these potential problems and their development is
exceptionally well laid out in this book.
But perhaps the main challenge for those who see fortification as an underutilized approach to address micronutrient
malnutrition (and I am one) is the one I alluded to in the first sentence of this foreword: communication. If someone
like me who has been involved in nutrition debates for 30 years used to think that food staple fortification was finished
business, then many more must also think the same. It is not. And the large-scale fortification community needs to do a
much better job of making the case that there is an unfinished agenda, that there is a cost of leaving it unfinished, and
that there is a clear path to finishing the job, all the while providing investors with a clear set of priorities and costings
for completing it.
To its great credit, this book helps to communicate not only the challenges and the solutions that have been devel-
oped to complete the unfinished fortification agenda, but also why it matters so much that solutions are found and how
they can be implemented. If you read it, you will be more fortified to help complete the unfinished fortification agenda.

Lawrence Haddad
GAIN Global Alliance for Improved Nutrition

xvii
Section I

Need and Approach

Chapter 1
Food Fortification: Past Experience,
Current Status, and Potential for
Globalization
M.G. Venkatesh Mannar1 and Richard F. Hurrell2
1
University of Toronto, Toronto, ON, Canada, 2Swiss Federal Institute of Technology, Zurich, Switzerland
Chapter Outline
1.1 Background
1.2 Early Successes With Food Fortification
1.3 Types of Fortification
1.4 Selection of Vehicles
1.1 BACKGROUND
Micronutrient deficiencies are a major, global public
health problem that can affect all age groups in both
industrialized and developing countries. One hundred
years ago multiple micronutrient deficiencies were com-
mon in poor rural and urban communities of industrial-
ized countries. They were largely eliminated as economic
conditions improved by an improved diet which included
micronutrient-fortified foods as well as more access to
animal source foods. Some deficiencies however, such as
in iron and iodine, still persist, while others such as folic
acid, B12, calcium, or vitamin D have emerged or
reemerged.
At the present time, micronutrient deficiencies in the
developing world are far more severe than in industrial-
ized countries and are a major impediment to the future
development of many nations. Some 2 billion people,
mainly women and children in developing countries, are
reported to suffer from iron, iodine, vitamin A, and zinc
deficiencies. Such deficiencies lead to a range of disabil-
ities including impaired brain development and cognition,
impaired immunity against disease, poor pregnancy out-
come, poor growth, impaired work capacity, blindness,
and even death. Multiple micronutrient deficiencies often
occur in the same individual and are primarily due to the
regular consumption of plant-based diets that include little
or no animal source foods or, in the case of iodine and
Food Fortification in a Globalized World. DOI: https://doi.org/10.1016/B978-0-12-802861-2.00001-8
Copyright © 2018 Elsevier Inc. All rights reserved.
3 1.5 Biofortification 8
5 1.6 Current Situation, Issues and Challenges 9
6 1.7 Concluding Thoughts 10
7 References 11
selenium deficiencies, they are due to low levels of these
micronutrients in soil leading to low levels in plant and
animal foods. Such diets provide intakes for a range of
micronutrients that are below the individual’s metabolic
needs. These low micronutrient intakes, coupled with
widespread infections, poor hygiene, and poor sanitation
in developing countries, lead to a variety of poor health
outcomes that restrict the intellectual potential of the indi-
vidual, reduce the earning power of the family, and
decrease the gross domestic product (GDP) of the coun-
try. This situation calls for the urgent action.
There are several approaches to increasing micronutri-
ent intake. They include the fortification of staple foods,
condiments, infant foods, and some industrial products;
the biofortification of food staples by plant breeding tech-
niques, dietary diversification; and supplementation with
pharmacological doses. In developing countries, addi-
tional public health interventions including infection con-
trol, improved hygiene and sanitation, and promotion of
breast-feeding may also be necessary if micronutrient sta-
tus is to be improved. Dietary diversification is easier for
the more affluent populations who can afford animal
source foods, and biofortification is most useful for low-
income populations in developing countries who consume
mainly locally grown foods and have little access to pro-
cessed foods. These food-based approaches are primarily
designed to prevent micronutrient deficiencies. Periodic
3
4 SECTION | I Need and Approach
supplementation with pills or capsules containing pharma-
cological doses of micronutrients can be used to prevent
or treat deficiencies and has been commonly used to pro-
vide additional vitamin A and a combination of iron and
folic acid.
Fortification of widely consumed foods with vitamins
and minerals is a public health strategy to enhance nutri-
ent intakes of the population without increasing caloric
intake. Food fortification is a medium- to long-term solu-
tion to alleviate specific nutrient deficiencies in a popula-
tion. National fortification programs involve the addition
of measured amounts of nutrient-rich “premix” containing
the required vitamins and minerals to commonly eaten
foods during processing. Populations with lower purchas-
ing power consume mainly staple foods and condiments,
making these foodstuffs the ideal vehicles to provide
micronutrients and to prevent the development, or to
decrease the prevalence, of micronutrient deficiencies.
The foods identified for fortification must be commonly
eaten foods that are centrally processed. This allows the
fortification process to be dovetailed into the existing
food production and distribution systems. In this way,
existing food patterns do not change and there is no need
for special compliance of the individual. In most develop-
ing countries, the choice of vehicles is limited to a hand-
ful of staple foods and condiments such as cereals, oils
and fats, sugar, salt, and sauces. The vitamins and miner-
als used for fortification typically include vitamins A, D,
folic acid and other B-complex vitamins, iodine, iron, and
zinc. The start-up cost for food fortification is relatively
inexpensive for the food industry, and often the recurrent
costs can be passed on to the consumer. The benefits of
fortification can extend over the entire life cycle of
humans. Food fortification is thus one of the most cost-
effective means of overcoming micronutrient malnutri-
tion, and as such has played an important role in its
implementation in public policy. According to the World
Bank “. . .probably no other technology available today
offers as large an opportunity to improve lives and accel-
erate development at such a low cost and in such short a
time” (World Bank, 1994).
There is, however, no one single model appropriate
for all population segments, making it imperative to
design and implement complementary approaches to
ensure the greatest penetration of fortified food products.
There are also specific situations where large-scale food
fortification can be enhanced by targeted fortification to
reach vulnerable population subgroups, such as home for-
tification for vulnerable families, complementary foods
for infants and young children (micronutrient powders,
lipid-based nutrient supplements, fortified blended foods,
etc.), and special foods for older children and pregnant
and lactating women (biscuits, yogurt, beverages, etc.)
(Moench-Pfanner et al., 2012).
Many national food fortification programs have been
introduced in both industrialized and developing countries
over the last 70 years and have played an important role
in improving public health. In the United States and
Canada enriched and/or fortified foods contribute a large
proportion of the intakes of vitamins A, C, and D as well
as thiamine, iron, and folate. Micronutrient deficiencies
have been greatly decreased or, as with iodine, virtually
eliminated on a global scale. Progress has accelerated in
the past decade. Today there are salt iodization programs
in approximately 140 countries worldwide, 83 countries
have mandated at least one type of cereal grain fortifica-
tion, 20 countries fortify edible oils, nine countries fortify
sugar, and several others fortify rice, milk, or condiments.
The current low levels of iron deficiency in the United
States have been attributed to fortified foods, with almost
one-quarter of iron intake in the US diet coming from for-
tified foods, much of that from cereal products.
Nevertheless, while many well controlled scientific stud-
ies have demonstrated the efficacy of iron-fortified foods,
the impact of large-scale iron fortification of cereal flours
on improving iron status in national populations has only
recently been confirmed (Barkley et al., 2015; Martorell
et al., 2015).
Another success has been folic acid fortification, and
since 1998, following the introduction of mandatory
folic acid fortification of cereal-grain products in
the United States, Canada, and Chile, there was a
30% 70% reduction of neural tube defects (NTD’s) in
newborns, encouraging some 75 other countries to add
folic acid to flour. A few countries have resisted how-
ever due to concerns over consumer safety. Market
driven industrial foods have also played a role in
alleviating micronutrient malnutrition in industrialized
countries. In Europe, a comparative analysis of dietary
surveys suggests that fortified foods, especially voluntar-
ily fortified breakfast cereals in France, Ireland, the
United Kingdom, and Spain have usefully contributed to
increasing vitamin and mineral intakes during childhood
and adolescence.
The introduction of dietary reference values in 1942
by the United States gave the first clear indication of the
quantities of micronutrients needed in diets so as to main-
tain optimum health. These have been updated and
extended several times by the United States, WHO, and
many other countries, and are the yardstick for defining
the fortification level of micronutrients added to foods.
The introduction of a tolerable upper limit for most nutri-
ents protects the consumer from overfortification. A
major step forward in standardizing food fortification
practices was the publication of the WHO guidelines for
the fortification of foods with micronutrients. These
appeared in 2006 (WHO/FAO, 2006) and were updated
for wheat and maize flour in 2009 (WHO, FAO,
 Food Fortification: Past Experience, Current Status, and Potential for Globalization Chapter | 1
UNICEF, GAIN, MI, & FFI, 2009). The guidelines made
evidence-based recommendations with respect to fortifica-
tion compounds, fortification vehicles, and importantly
they described how to define a fortification level. The
guidelines also discuss monitoring and evaluation of forti-
fication programs, introducing fortification legislation,
the need for advocacy, and cost-effectiveness based on
the expected health benefits.
The Lancet Maternal and Child Nutrition Series
(Maternal and Child Nutrition Study Group et al., 2013),
the Copenhagen Consensus and the Scaling up Nutrition
(SUN) Movement all recognize and endorse staple food
fortification as a sustainable, cost-effective intervention
with a proven impact on public health and economic
development. The Copenhagen Consensus Center is a
think tank that uses cost benefit analysis to establish pri-
orities for advancing global welfare. Each year a range of
global problems are evaluated and ranked by a panel of
economists that includes Nobel laureates. In 2008, the
expert panel considered 10 great global challenges. The
panel noted the exceptionally high ratio of benefits to
costs of micronutrient interventions and they ranked
micronutrient supplementation (vitamin A and zinc) as
the top priority, with micronutrient fortification (iron and
salt iodization) as priority number three, and biofortifica-
tion as priority number five. In 2012, the Copenhagen
Consensus recommended increasing micronutrient intake
by one or more of the different strategies as the number
one priority for the greatest return on investment
(Copenhagen Consensus, 2012). They noted that GDP
losses from undernutrition can be 2% 3% per year.
According to the Copenhagen Consensus, the return on
investment of food fortification is one of the highest
development dividends. For example, in the case of
iodine, the cost of salt iodization is less than 20 US cents
per person per year, and for every $1 spent, the saving is
as much as $30 in higher medical and nonmedical expen-
ditures. A rough estimate for low- and middle-income
countries suggests the cost benefit of fortification is
around 30:1.
Although food fortification is common in the industri-
alized countries, there are still important issues to resolve.
These include the safety of folic acid fortification, the
need for vitamin D fortification, and ensuring that fortifi-
cation does not provide excess levels of micronutrients
and cause negative health consequences. It is in low- and
middle-income countries however that we are entering the
new era for scaling-up fortification programs, for while
the potential health impacts are well appreciated, the
implementation science is less well developed. The first
Global Summit on Fortification held in Arusha, Tanzania
in September 2015 (The #FutureFortified Global Summit
on Food Fortification, 2016) called for national govern-
ments to invest more in technical support, oversight, and
5
compliance of food fortification programs. They stressed
the need for enforcement of fortification standards, better
advocacy to governments on the cost effectiveness, more
evidence to guide fortification policy and program design.
In order to ensure more transparent accountability, they
also called for an annual report on the state of fortification
globally.
All aspects of global food fortification are covered in
the following chapters beginning with the current global
prevalence of micronutrient deficiencies, daily recom-
mended micronutrient intakes, the different interventions
that can increase micronutrient intake, and food fortifica-
tion technologies. This is followed by a discussion of the
different delivery models including large-scale govern-
ment mandated programs, industry market-driven foods,
food aid and publicly distributed foods, and biofortifica-
tion of staple foods. The main food fortification vehicles
and the critical micronutrients are discussed individually
and a special effort has been placed on scaling up and
implementation of new national programs. This includes
financial and business considerations, cost-effectiveness,
public private partnerships, consumer awareness,
advocacy, quality control, regulatory monitoring, role of
government, and impact evaluation.
This overview chapter sets the scene for food fortifica-
tion, describing the historical development and first
successes, the different types of fortification, the choice
of the food vehicle, the development of large-scale
national programs, and points out current issues and
challenges.
1.2 EARLY SUCCESSES WITH FOOD
FORTIFICATION
We tend to forget that the widespread micronutrient defi-
ciencies that are reported today in low- and middle-
income countries were once common in the poor urban
and rural populations of Europe and the United States.
Goiter, cretinism, anemia, rickets, pellagra, and xeroph-
thalmia were common illnesses until the early 20th
century, at a time when vitamins were being discovered,
and when low intakes of vitamins and minerals were
being linked to the common diseases that so increased
morbidity and mortality. Food fortification with micronu-
trients was a part of the public health response to prevent
these illnesses and was rewarded with some remarkable
successes (Semba, 2012).
The first micronutrient deficiency to be targeted by
public health programs was iodine and the first fortified
food to be introduced was iodized salt to prevent goiter
and cretinism. Fortification of salt with iodine was intro-
duced in Switzerland in 1923 and Michigan, USA in
1924. Its success led to the voluntary iodization of salt
6 SECTION | I Need and Approach
throughout the United States and the virtual elimination
of iodine as a serious public health problem by the late
1930s. At about the same time, it was reported that
iron-fortified milk decreased anemia prevalence in
infants, although, in 1911 14, the United States had
taken an alternative approach to treat the anemia in school
children in the rural South. They targeted the widespread
hookworm infections and took measures to improve sani-
tation and hygiene, resulting in increased hemoglobin
concentrations, increased growth, and better performance
on mental development tests, providing a strong reminder
that anemia has multiple causes and may need multiple
interventions to eliminate completely.
By the end of the 1930s, the chemical structures of the
major vitamins were known, and most could be synthe-
sized enabling their addition to food. At that time, vitamin
A deficiency was widespread in Europe especially in
Denmark where it resulted in a high mortality of children.
Vitamin A was first added to margarine voluntarily in the
United Kingdom in 1927 and this practice became manda-
tory during the Second World War in order to achieve
nutritional equivalence to butter.
Rickets was common in children who lived in the
industrial cities of North America and Europe from the
17th until the early 20th century when over 85% of
the children living in these areas had rickets, primarily
due to lack of sunshine and insufficient production of
vitamin D in the skin. As soon as it was synthesized in
the 1930s, it was used to fortify milk in Europe and North
America which resulted in the eradication of rickets as a
major health problem in children.
In the early 20th century, pellagra was common in
the maize eating populations of the southeast United
States. At the peak of the epidemic (1928 30), 7000
individuals died per year from pellagra due to niacin
deficiency. Lime treatment of maize, commonly used in
Central America, and which releases niacin from its
nonbioavailable form, was not practiced. Voluntary
enrichment of bread and other grain products with niacin
was implemented in 1938 and mandatory fortification
followed in 1940 and, as a result, pellagra had become
almost nonexistent by 1950. Iron, thiamine, niacin, and
riboflavin were required to be added to wheat flour and
other cereal products to replace nutrients lost during
the milling process and to reduce the risk of anemia,
beriberi, pellagra, and riboflavin deficiency respectively
(Semba, 2012). These early successes paved the way in
the latter half of the 20th century for widespread
fortification in industrialized countries of flour, salt,
milk, infant foods, and manufactured foods such as
breakfast cereals and beverages, and are the impetus
for the globalization of food fortification and the imple-
mentation of new programs in low- and middle-income
countries.
1.3 TYPES OF FORTIFICATION
In 1987, the Codex Alimentarius Commission outlined
general principles for adding nutrients to foods (Codex
Alimentarius, 1987). It used the terms “fortification” and
“enrichment” interchangeably, with the following defini-
tion: “Fortification or enrichment means the addition of
one or more essential nutrients to a food whether or not it
is normally contained in the food for the purpose of pre-
venting or correcting a demonstrated deficiency of one or
more nutrients in the population or specific population
groups.” The United States has made the most consistent
efforts in establishing food fortification policy and to
guide fortification programs. The FDA currently endorses
the addition of nutrients to food under four conditions
These are nutritional deficiencies (e.g., salt iodization);
restoration of nutrient losses (such as the addition of
micronutrients to white wheat flour); improving the qual-
ity of replacement food (the original rationale for fortify-
ing margarine); and to balance the nutrient content of
industrially fabricated foods that replace large proportions
of the natural diet. The FDA endorses a standard profile
of 22 nutrients for addition to these new foods.
Fortified foods and fortification programs can be
designed, delivered, and controlled in different ways
depending on the extent of involvement of the private and
public sectors. Programs can be designed for mass fortifi-
cation, targeted fortification, or market-driven fortifica-
tion. Mass fortification refers to the addition of one or
more micronutrients to staple foods or condiments that
are widely consumed by a general population that has an
unacceptable public health risk of being deficient in these
micronutrients. Flour fortification with iron and folic
acid, and salt iodization are good examples. This type of
fortification is usually led by governments but may be
voluntary or mandatory. It reaches all sections of the pop-
ulation including the most at risk groups, such as women
and children, but mass fortification also provides micro-
nutrients to those population groups such as adult men
who are already consuming enough micronutrients to
meet their requirements. This creates the possibility of
excess intake and the potential of negative health conse-
quences if not well controlled. The additional cost of the
micronutrient premix for mass fortification is a major fac-
tor in low- and middle-income countries when introducing
a program, as is ensuring the collaboration of all stake-
holders, particularly those in government and industry,
but also academia, non governmental organization
(NGO’s) and consumers.
Targeted fortification refers to fortified foods that are
designed for, and targeted at, a specific population group.
The population group is most often infants and young
children but any population group could be targeted
including adolescents, young women, pregnant women, or
 Food Fortification: Past Experience, Current Status, and Potential for Globalization Chapter | 1
even food aid for displaced persons. Unlike mass fortifi-
cation, the targeted fortified foods are rarely fortified with
a single or even a small number of micronutrients. They
are usually fortified with range of critical micronutrients
for which the targeted population is at risk of deficiency.
Industrially manufactured complementary foods for young
children, often based on cereals with milk or legumes, are
the main targeted fortified food in this category.
Complementary foods are consumed from 6 months of
age, as the infant moves from breast milk as the sole
source of nutrition to an intermediate weaning diet, until
around 2 years when the young child moves onto the nor-
mal family diet. The composition of manufactured com-
plementary foods is recommended and regulated by
government and international agencies so as to ensure
that the child receives adequate nutrition in the period
between breast feeding and consuming the family diet.
Infant formulas, which may be needed to replace breast
milk, are also strictly regulated in composition of micro-
and macronutrients and are formulated to cover all the
nutrient requirements of the infant.
In Europe, North America, and other industrialized
countries, some mothers wean their children from breast
milk with home-produced complementary foods, however
others purchase manufactured fortified complementary
foods from shops or pharmacies. In developing countries,
families cannot afford to purchase manufactured comple-
mentary foods and the home-produced cereal gruels, that
are fed as complementary foods to young children, are
deficient in many micronutrients and often also in energy.
Public health programs that supply fortified complemen-
tary foods to infants and young children have been intro-
duced by international agencies in some developing
countries and may also be distributed by national govern-
ments through targeted/subsidized programs. Poorer fami-
lies in the United States can also obtain complementary
foods through a government organized public distribution
system (Special Supplemental Nutrition Program for
Women, Infants and Children (WIC)). In recent years, a
common and least costly way of fortifying complemen-
tary foods for young children in the developing world has
been through the distribution of sachets of micronutrient
powders. The powder is sprinkled daily onto the gruel at
the time of consumption. Such products contain a multi-
micronutrient mixture designed to provide all the micro-
nutrients missing from the regular diet. More recently
fortified lipid based supplements have been similarly
added to gruels fed to children so as to provide both the
missing micronutrients and additional energy.
Market driven fortification refers to those manufac-
tured foods which are fortified both for the marketing
advantage of the company and for the benefit of the con-
sumer: The food manufacturers use the nutritional benefit
of the consumer as a marketing advantage, while
7
complying with government regulations in respect to the
nature and quantity of the specific nutrient added. The
fortified foods are targeted at specific population groups.
Breakfast cereals and chocolate drink powders, e.g., are
targeted at children and adolescents. They are commonly
fortified with a range of micronutrients at around 30% of
the daily requirement and, when widely consumed, can
provide useful amounts of those micronutrients often
lacking in the diet. In low-income countries, targeted for-
tified foods are usually out of reach for the poorer com-
munities that are most in need of micronutrients, however
cost is generally not an issue in the higher socioeconomic
groups in the developing world or industrialized countries.
In general, because of the epidemic of overweight in
North America and Europe, and the double burden of
under nutrition and overweight in low- and middle-
income countries, high energy snack foods such as car-
bonated beverages and confectionary are not considered
suitable as targeted fortification vehicles
Food fortification is governed by national regulations
whether it is mandatory or voluntary. Government legisla-
tion mandates many national mass fortification programs
describing the food vehicle and the nature and level of the
micronutrients to be added. National fortification policies
may also provide guidance on when it is appropriate to
add nutrients to foods (e.g., restoration; correcting dietary
insufficiency; avoiding nutritional inferiority and main-
taining a balanced nutrient profile in a food like a meal
replacement). Monitoring and enforcement of the regula-
tions is not always strong in developing countries, how-
ever mandatory mass fortification programs usually have
a better chance of success. Government regulations and
international recommendations also exist for voluntary
fortification and allow the food industry to add micronu-
trients to foods as long as they conform to specifications.
Market driven fortification is always voluntary, whereas
targeted fortification can either be mandatory or
voluntary.
1.4 SELECTION OF VEHICLES
When a country or region is ready to implement food for-
tification, the process begins by identifying the commonly
eaten foods that can act as vehicles for one or more
micronutrients. To better define the fortification level,
WHO (WHO/FAO, 2006) recommends dietary surveys to
define micronutrient intake and consumption of potential
food vehicles in these different population groups. Using
these guidelines, fortification programs provide meaning-
ful levels of the micronutrients (e.g., 30% 50% of the
daily adult requirements) at average consumption of one
or more food vehicles. The levels also need to take into
account variations in food consumption so that the safety
of those at the higher end of the scale and impact for
8 SECTION | I Need and Approach
those at the lower end are ensured. They should also con-
sider prorated intakes by young children to ensure effica-
cious and safe dosages. Cost, bioavailability, sensory
acceptability, and storage stability are some of the criteria
that determine the best match between the nutrient and
food vehicle.
Common food vehicles that can be fortified include
wheat and wheat products, maize, rice, milk and milk pro-
ducts, cooking oils, salt, sugar, and condiments. As pro-
cessed foods such as breakfast cereals and chocolate drink
powders gain popularity and market reach in low and
middle-income countries, they offer new channels for
micronutrient delivery. If potential food vehicles are
represented as a pyramid, staple foods are at the base of
the pyramid as they are cost-effective to fortify on a mass
scale. Basic foods, such as breads and biscuits, packaged
cereals and flours, and dairy products are in the middle;
and market driven fortified foods such as convenience
and ready-to-eat foods are at the top. Condiments such as
salt, sugar, fish and soy sauce, and bouillon cubes fit at
different levels of the pyramid depending on the relative
fortification cost increase to what is originally an inexpen-
sive foodstuff.
Fortifying less expensive staple foods at the base of
the pyramid results in broader dissemination of micronu-
trients throughout the population, particularly to the poor.
Also, fortifying foods at the base of the pyramid has a
better chance of fortifying products through the other tiers
of the pyramid because staple foods are generally used to
produce basic and value-added foods.
Each food vehicle offers specific opportunities and
constraints:
Cereals: Staples such as rice, corn, and wheat that are
milled at centralized locations have the potential to
reach large populations and are used in several coun-
tries as vehicles for multiple nutrients. Staple cereals
milled at the community level pose a challenge
because of quality and safety constraints. For fortify-
ing whole grain cereals such as rice, there is now a
technology to extrude a simulated rice grain premix.
Fats and oils: Cooking fats and oils offer an option to
deliver fat soluble vitamins such as vitamin A and D.
While they have an advantage in that they are often
centrally refined and packed, there is still the chal-
lenge of a large proportion being sold in an unbranded
form. Packaging in opaque containers is critical to
protect the vitamins from degradation.
Condiments: Salt, sugar, spices, and sauces are attrac-
tive carriers. Some are processed centrally and con-
sumed in regular quantities and offer great potential.
Recent studies show the promise for salt double forti-
fied with iron and iodine.
Dairy products: Areas where milk is processed in
dairies, may offer an option for fortification with both
vitamins and minerals.
Market-driven fortified foods: Given the global
demographic shifts from rural to urban areas, a larger
proportion of the population can now be reached via
commercially processed foods and value-added
products. However, the most vulnerable populations
consume these higher priced products only
sporadically.
A multifaceted approach of fortifying more than one
food vehicle is a good strategy, especially when a univer-
sally consumed vehicle is not available. When multiple
foods are fortified, each with a portion of the estimated
average requirements per single serving, the possibility of
consuming unsafe levels of a micronutrient through
excess consumption of a single food becomes more
remote.
1.5 BIOFORTIFICATION
Systematic planning and research over the past two dec-
ades suggests that biofortification, the process by which
the nutritional quality of food crops is improved through
agronomic practices, conventional plant breeding, or
modern biotechnology can raise essential nutrient content
and offer a long-term solution to improving intakes and
preventing micronutrient deficiencies. Biofortification
differs from conventional fortification in that biofortifica-
tion aims to increase nutrient levels in crops during plant
growth rather than through manual means during posthar-
vest processing of the crops. Key concepts underlying a
rationale for staple food biofortification are the achieve-
ment of sustained nutrient enrichment of local staple
crops, a potential for improved crop resilience, produc-
tivity, and agronomic value, and a structure for introduc-
tion into the community aimed at reaching the rural poor.
Biofortification may therefore present a way to reach
populations where supplementation and conventional
fortification activities may be difficult to implement
be limited (Bouis et al., 2011). Examples of biofortifica-
tion projects include: iron-biofortification of rice,
beans, sweet potato, cassava, and legumes; zinc-
biofortification of wheat, rice, beans, sweet potato, and
maize; provitamin A carotenoid-biofortification of sweet
potato, maize, and cassava. A novel characteristic of
biofortification may be its permanence in nutrient enrich-
ment: once a nutrient-enriched staple crop has been
bred, adapted, and grown in a region, the nutrient incre-
ment is, without continued plant breeding innovations,
perpetual.
 Food Fortification: Past Experience, Current Status, and Potential for Globalization Chapter | 1
1.6 CURRENT SITUATION, ISSUES AND
CHALLENGES
Notwithstanding the considerable progress in food fortifi-
cation over the past decades, there are major challenges
to ensure that undernourished people especially in low-
and middle-income countries receive meaningful amounts
of micronutrients through improved access to fortified
foods. The following section discusses the current situa-
tion with respect to fortification programs designed to
prevent specific micronutrient deficiencies, and highlights
some remaining issues and challenges.
Vitamin A: Guatemala’s sugar fortification program
has virtually eliminated vitamin A deficiency; and big
reductions in vitamin A deficiency have also been reported
in El Salvador and Honduras, where fortification was com-
bined with supplementation. Similar approaches in Zambia
beginning in 1998 demonstrated success in urban areas.
Since the poorer segments of the population in Africa and
Asia do not consume as much sugar as in Latin America,
countries such as Nigeria, Morocco, Yemen, Bangladesh,
and Pakistan are implementing national programs to fortify
cooking oils with vitamin A. Because of the high efficacy
of vitamin A fortification, safety is a concern, and care
must be taken not to over fortify.
Iodine: The most successful global fortification expe-
rience has been the fortification of salt with iodine.
Adding iodine to salt is a simple manufacturing process
costing no more than 4 cents per person annually. A sig-
nificant proportion of the populations in more than 120
countries have access to iodized salt. As of 2015, nearly
76% of salt consumed in the world is being iodized,
protecting nearly 80 million newborns each year from the
threat of mental impairment caused by iodine deficiency
(UNICEF State of the World’s Children, 2015).
Successful salt iodization has reduced the incidence of
goiter and cretinism, prevented mental retardation and
subclinical iodine deficiency disorders, and contributed to
improved national productivity. Building on the success
with iodization, double fortification of salt with iodine
and iron is gaining ground and can be integrated with
established iodization processes. Double fortified salt is
currently being produced in India and has the potential to
be distributed through commercial channels and public
programs to reach economically weaker sections of the
population in many countries.
Nevertheless, despite the relative success of salt iodi-
zation, there are population groups in many countries still
without access to iodized salt. These groups are often
those most vulnerable and are in the greatest need of pro-
tection against iodine deficiency. While the relatively eas-
ier task of getting compliance with iodine fortification
guidelines from the large- and medium-scale salt industry
9
units has been achieved, compliance by small- and some
medium-scale salt producers continues to pose challenges.
Thus, the strategies used to achieve 70% coverage of
iodized salt globally will not necessarily result in addres-
sing the challenge for the remaining 30% of the popula-
tion. The time needed for a fortification intervention to
become effective in low- and middle-income countries is
likely to be much longer than in developed countries
because in the former, such vehicles as salt are often pro-
cessed in a large number of widely-dispersed cottage-
scale industries that are less professionally managed.
Iron: the global prevalence of iron deficiency is high
but unlike with iodine and vitamin A, it has been much
more difficult to demonstrate conclusively that national
iron fortification programs have increased iron status and
improved health. One difficulty in demonstrating the
impact of iron fortification has been that iron deficiency
does not lead to an easily identifiable deficiency disease
that can be eradicated in the same way as goiter or
xerophthalmia. Iron deficiency leads to retarded brain
development, poor pregnancy outcome, decreased work
performance, and anemia, all of which have multiple
etiologies,
Another difficulty has been the choice of the iron for-
tification compound and the definition of the iron fortifi-
cation level. A major problem has been that the more
bioavailable, soluble iron compounds often cause frequent
color and flavor changes in some food vehicles, whereas
the organoleptically acceptable, more insoluble com-
pounds are less well absorbed. Another challenge is that
cereal flours, the major iron fortification vehicle, are high
in phytate, a potent inhibitor of iron absorption. Solutions
have been found in recent years as a result of iron absorp-
tion studies in women and children and long-term efficacy
studies that have identified alternative iron compounds
and have devised ways of overcoming the inhibitory
effects of phytic acid. A recent systematic review of 60
efficacy trials concluded that consumption of iron-
fortified foods results in an improvement in hemoglobin,
serum ferritin, and iron nutrition (Gera et al., 2012).
Additionally, Costa Rica clearly demonstrated recently
that a national program fortifying milk powder and maize
flour with iron markedly decreased anemia prevalence in
women and children (Martorell et al., 2015).
Unfortunately, the use of anemia prevalence to monitor
iron fortification programs can also be problematic if the
observed anemia has other etiologies in addition to iron
deficiency. Hookworm, malaria, hemoglobinopathies, and
inflammatory disorders are major causes of anemia in
many Africa and Asian countries and they may overlap
with iron deficiency. Clearly, other interventions in addi-
tion to iron fortification are necessary to decrease anemia
prevalence in these countries.
10 SECTION | I Need and Approach
Folic acid: NTD’s occur when the neural tube fails to
close early in pregnancy resulting in spina bifida and
anencephaly. In 1991, it was reported that supplemental
folic acid reduced the recurrence of NTD in women with
a previous history of an NTD pregnancy. To impact
NTDs, folate must be consumed before conception. The
situation is complicated however by some women having
genetic polymorphisms in folate metabolism, resulting in
higher folate requirements than the general female popu-
lation. Flour was fortified with folic acid in the US in
1998, and in 2014 some 75 countries were likewise forti-
fying wheat, maize, or rice with folic acid to reduce the
risk of folic acid preventable spina bifida and anenceph-
aly. Market-driven foods fortified with folic acid are also
common. Mandatory folic acid fortification of flour has
been described as the most important science-driven nutri-
tion and public health intervention in decades. Folic acid
status has markedly improved in many countries, and
NTDs have been dramatically decreased in the United
States by 19% 32% and, in a range of other countries,
from 19% to 55%. Bell and Oakley (2009) estimated that
27% of the world’s population has access to folic acid-
fortified flour, but that only 10% of the preventable birth
defects are currently prevented due mainly to poor cover-
age in low- and middle-income countries.
There are however some issues. Folic acid fortification
is targeted at young women with an increased requirement
for folate, not at a general population with low folate
intakes or with a reported low folate status. In Canada,
e.g., which has fortified flour with folate, ,1% of
Canadians were reported to be folate deficient and 40%
had high red cell folate concentrations. The blood folate
concentration needed to achieve a maximum reduction in
folate sensitive NTDs however is unknown, although it is
considered to be much higher than the levels set for folate
deficiency. There are potential adverse health effects of
high folate intakes and concern has focused on the possi-
bility that increased folic acid could mask anemia caused
by B12 deficiency resulting in neurological damage and a
higher risk of memory impairment. The potential for folic
acid fortification to increase colorectal cancer has also
been raised, although after almost 20 years of folic acid
fortification in the United States no evidence has emerged
to support this possibility. Recent focus has shifted to the
possibility that folic acid fortification, because of its role
in methylation reactions, might lead to changes in epige-
netic patterns and might explain different health outcomes
amongst individuals with similar genetic backgrounds.
Vitamin D: synthesis in the skin is the primary source
of vitamin D, however many people particularly the
elderly and those in northerly latitudes rely on dietary vita-
min D to maintain an adequate status. Vitamin D however
is not widespread in foods and is found naturally at low
concentrations in a few foods only. Vitamin D intakes in
Europe, North America, and many other countries are far
below dietary reference intakes established assuming mini-
mal sun exposure, and vitamin D deficiency is currently
reported in many parts of the world. One complication is
the disagreement on the references ranges for
25-hydroxyvitamin D that represent adequate vitamin D
status. Lower cut-off values have been recommended for
the prevention of rickets and osteomalacia, whilst much
higher cut-off values have been proposed for the preven-
tion of falls and fractures in the elderly. The choice of
vehicles is also problematic, and even in populations
where fluid milk or margarine are voluntarily or manda-
tory fortified, much of the population still consumes less
vitamin D than is recommended as milk is now less widely
consumed. Alternative or perhaps multiple food vehicles
are required for vitamin D fortification. In the United
States, in addition to milk, yoghurt, butter, margarine,
cheese, orange juice, and bread have been voluntarily forti-
fied and wheat flour has been suggested as another option.
1.7 CONCLUDING THOUGHTS
The sound science base that has resulted from much
research in recent years, and the vast experience with
fortification programs in industrialized countries, means
that food fortification is ready for globalization, and ready
to target those micronutrient deficiencies highly prevalent
in low- and middle-income countries, as well as those still
not eradicated in the industrialized world.
We should proceed with care however, for while the
addition of micronutrients to foods can help maintain and
improve the nutritional quality of diets, indiscriminate
fortification of foods could lead to overfortification or
underfortification of micronutrients, and could cause a
nutrient imbalance in the diet. Any changes in food forti-
fication policy for micronutrients must therefore be con-
sidered within the context of the impact the changes will
have on all segments of the population, and whether
policy changes need technology changes or influence
safety considerations (Dwyer et al., 2014).
In addition to these programmatic challenges, there
are differences in perceptions concerning fortification.
While it is well established that food fortification has a
positive impact on a population’s health and well-being
that by far outweighs any potential risk, historically there
has been public opposition in some countries to the addi-
tion of a foreign substance to food or water. Opponents of
fortification argue that nutritional education with respect
to a well-balanced diet is a more logical approach than
fortification. At the other end of the scale, the nutritional
supplement and vitamin industry promotes the view that
it is better for people to consume multivitamin supple-
ments. Other objections include the potential risk for neg-
ative health outcomes.
 Food Fortification: Past Experience, Current Status, and Potential for Globalization Chapter | 1
It is important to understand these different view-
points, but equally important to move forward in a
responsible way with what is most beneficial to the larg-
est numbers of people whose lives would otherwise be
compromised without the essential vitamins and miner-
als in their diet. What is needed is a balanced approach.
Together with food fortification programs, public health
interventions should focus on the elimination of other
underlying causes of micronutrient deficiencies. In the
developing world, e.g., these could include improve-
ments in sanitation that would decrease hookworm
infection and improve iron status through reduced blood
loss; vaccinations to protect against measles infection
caused by decreased immunity because of Vitamin A
deficiency; and birth control that should improve the
standard of living of a family and result in a better qual-
ity diet.
REFERENCES
Barkley, J.S., Wheeler, K.S., Pachón, H., 2015. Anaemia prevalence
may be reduced among countries that fortify flour. Br. J. Nutr. 114
(2), 265 273.
Bell, K.N., Oakley, G.P., 2009. Update on prevention of folic acid-
preventable spina bifida and anencephaly. Birth Defects Res. Part A
85 (1), 102 107.
Bouis, H.E., Holtz, C., McClafferty, B., 2011. Biofortification: a new
tool to reduce micronutrient malnutrition. Food Nutr. Bull. 32
(Suppl. 1), 531 540.
Codex Alimentarius, 1987. General principles for the addition of essen-
tial nutrients to foods. Available at www.codexalimentarius.org.
11
Copenhagen Consensus, 2012. Expert Panel Findings. Copenhagen,
Denmark.
Dwyer, J.T., Woteki, C., Bailey, R., Britten, P., Carriquiry, A., Gaine, P.C.,
et al., 2014. Fortification: new findings and implications. Nutr. Rev. 72
(2), 127 141.
Gera, T., Sachdev, H.S., Boy, E., 2012. Effect of iron-fortified foods on
hematologic and biological outcomes: systematic review of random-
ized controlled trials. Am. J. Clin. Nutr. 96, 309 324.
Martorell, R., Ascencio, M., Tacsan, L., Alfaro, T., Young, M.F., Addo,
O.Y., et al., 2015. Effectiveness evaluation of the food fortification
program of Costa Rica: impact on anemia prevalence and hemoglo-
bin concentrations in women and children. Am. J. Clin. Nutr. 101
(1), 210 217.
Maternal and Child Nutrition Study Group, Black, R.E., et al., 2013.
Maternal and child nutrition: building momentum for impact. The
Lancet 382 (9890), P372-375.3.
Moench-Pfanner, R., Laillou, A., Berger, J., 2012. Large-scale fortifica-
tion, an important nutrition-specific intervention. Food Nutr. Bull.
33 (Issue 4_suppl. 3).
Semba, R.D., 2012. The historical evolution of thought regarding multi-
ple micronutrient nutrition. J. Nutr. 142, S143 S156.
The #FutureFortified Global Summit on Food Fortification. Event
Proceedings and Recommendations for Food Fortification Programs.
Sight & Life Magazine Supplement. 6 July 2016.
UNICEF State of the World’s Children 2015. UNICEF New York.
WHO, FAO, UNICEF, GAIN, MI, & FFI, 2009. Recommendations on
Wheat and Maize Flour Fortification. Meeting Report: Interim
Consensus Statement. World Health Organization, Geneva.
WHO/FAO, 2006. Guidelines on Food Fortification for Micronutrients.
World Health Organization, Geneva.
World Bank, 1994. Enriching Lives: Overcoming Vitamin and Mineral
Malnutrition in Developing Countries. Development in Practice,
Washington, DC.
Chapter 2

Prevalence, Causes, and Consequences of

Micronutrient Deficiencies. The Gap
Between Need and Action
Ian Darnton-Hill1,2
1
University of Sydney, Sydney, NSW, Australia, 2Tufts University, Boston, MA, United States

Chapter Outline
2.1 Introduction 13 2.2.4 Vitamin A Deficiency 19
2.2 The Gap in Micronutrient Intakes at Population Level and 2.2.5 Zinc 21
the Resultant Deficiency Outcomes Being Addressed 13 2.2.6 Other Micronutrients 22
2.2.1 Iron Deficiency and Anemia 15 2.3 Conclusions 24
2.2.2 Iodine 17 References 25
2.2.3 Folate and Neural Tube Defects (NTDs) 18 Further Reading 28

This chapter draws on a much longer overview of Food
Fortification prepared for the Micronutrient Forum (avail-
able on their website, currently maintained by the
Micronutrient Initiative www.mnf.org)
2.1 INTRODUCTION
Deficiencies of micronutrients (vitamins and minerals/
trace elements), and the resulting negative consequences
of such deficiencies, continue to be very significant public
health problems in much of the world (WHO, 2017;
Black et al., 2013; Darnton-Hill et al., 2017). Women and
young children in low- and middle-income country
(LMIC) populations (WHO, 2017; Allen, 2005) and
female adolescents (Thurnham, 2013) are especially at
risk (Darnton-Hill et al., 2017; Bailey et al., 2015).
Micronutrient malnutrition has widespread and important
consequences to both national health and economic well-
being (Horton et al., 2008; The World Bank et al., 1994;
Bhutta et al., 2013) with a small but important contribu-
tion to the total global burden of disease (Bhutta and
Haider, 2009; Darnton-Hill, 2012). The World Health
Organization (WHO) and the Food and Agriculture
Organization of the United Nations (FAO) have identified
four main strategies for improving micronutrient
Food Fortification in a Globalized World. DOI: https://doi.org/10.1016/B978-0-12-802861-2.00002-X
Copyright © 2018 Elsevier Inc. All rights reserved.
malnutrition: nutrition education leading to increased
diversity and quality of diets; food fortification; supple-
mentation; and, disease control measures (WHO/FAO
et al., 2006). It is now also widely recognized that without
parallel changes in socioeconomic and sociocultural
norms, these strategies are unlikely to be fully effective or
sustained (FAO/WHO, 2014). An increasingly important
part of the overall strategy is the large-scale fortification
of staple foods regularly eaten in diets consumed around
the world (Darnton-Hill et al., 2017; European
Commission, 2017).
2.2 THE GAP IN MICRONUTRIENT
INTAKES AT POPULATION LEVEL AND THE
RESULTANT DEFICIENCY OUTCOMES
BEING ADDRESSED
Over 1.6 to 2 billion people globally are estimated to be
at risk of micronutrient deficiencies such as anemia
(WHO/FAO et al., 2006; European Commission, 2017;
McLean et al., 2009; Stevens et al., 2013). A systematic
review of all studies published between 1988 and 2008
that reported on micronutrient intakes of women in
resource-poor settings found that over half of the studies
reported mean/median intakes of all the micronutrients
13
14 SECTION | I Need and Approach
measured as below recommended intakes (vitamins A and
C and niacin had especially low intakes at 29%, 34%, and
34% of Estimated Average Requirement (EAR), respec-
tively) (Torheim et al., 2010). While regional differences
were apparent, overall the review identified that women
living in resource-poor settings of LMIC commonly have
inadequate intakes of one or more micronutrients
(Torheim et al., 2010), confirming earlier studies (Allen,
2005), particularly in pregnancy (Darnton-Hill and
Mkparu, 2015). The deficiencies result in considerable
social and economic costs, usually with a negative gender
bias against females (Darnton-Hill et al., 2005).
Globally, the gap can be represented by the estimated
prevalence of deficiencies of each micronutrient
(Fig. 2.1). The burden of the global figure of around two
billion (WHO/FAO et al., 2006) is borne most by women,
including adolescents, and children (Bailey et al., 2015).
This leads, amongst other consequences, to the risk of
less than optimal development of 40% 60% of children
in the 6 24 month age group growing up in LMIC
(Alderman and Horton, 2007) and contributes to over
600,000 stillbirths or neonatal deaths and over 100,000
maternal deaths during pregnancy (Rowe and Dodson,
2012). At the same time, some 18 million newborns are
estimated to be born intellectually impaired as a result of
maternal iodine deficiency (Iodine Global Network IGN,
2015a; Rohner et al., 2014). Insufficient intake of vitamin
A results in approximately 350,000 cases of childhood
blindness, with a half of them dying within 12 months of
losing their sight and compromised immune system lead-
ing to at least 157,000 early childhood deaths due to
FIGURE 2.1 Magnitude of prevalence of micronutrient deficiencies worldwide (note: prevalence of low urinary iodine is based on a single spot
urine sample) (Muthayya et al., 2013).
diarrhea, measles, malaria, and other infections each year
(WHO, 2009; Palmer et al., 2017). It has been estimated
that each year, 1.1 million children under the age of five
die because of vitamin A and zinc deficiencies
(Micronutrient Initiative et al., 2009). Due to maternal
folate deficiency, over 300,000 children were estimated in
2006 to be born each year with severe birth defects
(March of Dimes et al., 2006). Just micronutrient defi-
ciencies alone have been estimated to cost an annual GDP
loss of 2% 5% (in LMIC) (Horton et al., 2008; Horton,
2006) with direct costs estimated to be between US$20 to
US$30 billion every year (Horton, 2006).
Other outcomes of the relatively poorer diets, and
compromised well-being and health in women and young
children in many LMIC are the substantially higher rates
of maternal mortality, stillbirth, and neonatal mortality in
the lowest compared to the highest income countries;
98% or more of these adverse outcomes occur in low-
income countries (Barros et al., 2015; Goldenberg and
McClure, 2012). Within countries, costs of micronutrient
malnutrition differ between socioeconomic status of sub-
populations, e.g., in the Philippines costs attributed to
micronutrient deficiencies in the poorest third of house-
holds were estimated to be five times higher than in the
wealthiest third (Wieser et al., 2013). Such disparities add
increased financial burdens to often already-overloaded
and underresourced health systems (WHO, 2010). While
reasons for disparities are not always known, they partly
at least relate to differences in access to health care
and resources and behavioral factors such as poor “seek-
ing-out behaviors” to both health care and specific
 Prevalence, Causes, and Consequences of Micronutrient Deficiencies Chapter | 2
interventions (Boerma et al., 2008). Consequently inter-
ventions like fortification that generally require less active
health and nutrition-seeking behaviors, and/or increases in
availability or access to improved dietary intakes, could
be expected to have an important impact (Darnton-Hill
et al., 2017).
2.2.1 Iron Deficiency and Anemia
Anemia is the most common and widespread nutritional
disorder in the world, affecting over 1.62 billion people in
both affluent and LMIC (Pasricha et al., 2013; Branca
et al., 2014). Iron deficiency occurs when physiological
demands are not met due to inadequate intake, absorption,
or utilization, or excessive iron losses (Pena-Rosas et al.,
2015) and has negative impacts even before developing
into actual iron deficiency anemia. While iron deficiency
is thought to be the most common cause of anemia glob-
ally (Petry et al., 2016), other nutritional deficiencies
(particularly folate, vitamin B12, vitamin A, copper); para-
sitic infections (including malaria, helminths, schisto-
somes such as hookworms); chronic infection associated
inflammation including HIV; and genetic disorders, such
as hemoglobinopathies like sickle cell disease, can all
cause anemia (WHO and FAO, 2004).
Recently estimated global anemia rates are 29% (496
million) of nonpregnant women, 38% of pregnant women
(32 million), and 43% of young children under five years
(273 million), but the ranges vary enormously (Stevens
et al., 2013) by socioeconomic and geographical location.
As most are women of reproductive age or young children
(Stevens et al., 2013; WHO, 2015) in LMIC, every sec-
ond pregnant woman and about 40% of preschool chil-
dren are anemic. Rates for children under 5 years of age
go as high as 70%, 74%, and 80% in South Asia, East
Africa, and Central and West Africa respectively, c.f.
11% in high-income regions (Stevens et al., 2013).
Similar figures for pregnant women range from 23% in
high-income countries compared to 53%, 46%, and 61%
for South Asia, East Africa, and Central and West Africa.
In Latin America and the Caribbean prevalence rates of
anemia among children under 6 years of age ranged from
Chile (4.0%) to a severe public health problem of over
40% in Bolivia, Guatemala, and Haiti, and for women of
childbearing age from 5.1% in Chile to the highest rates
in Panama (40%) and Haiti (45.5%) (Martorell et al.,
2015).
It has been estimated that an average of 50% of ane-
mia is due to iron deficiency in women, rising to 60% for
pregnant women, and in children about 42% (Stevens
et al., 2013). The proportion directly attributable to iron
deficiency is very geographically variable, and a recent
review suggests there is large heterogeneity between
countries and so may be nearer to 25% for children and
15
37% for nonpregnant WRA in many LMIC (Petry et al.,
2016; Zimmermann and Hurrell, 2007). Estimates of ane-
mia prevalence derived from the hemoglobin concentra-
tion measurements alone do not allow properly for the
contribution of iron deficiency or the role of other causes
of anemia (Petry et al., 2016). Currently available iron
indicators are more difficult to interpret in populations in
LMIC due to this multifactoral etiology of anemia
(Lynch, 2012). Current estimates, using hemoglobin
levels, are nevertheless shown in Fig. 2.2 as they reflect
the severity and geographic extent of the problem, even
imperfectly.
2.2.1.1 Health and economic consequences of
anemia and iron deficiency
The health and economic consequences of this high prev-
alence of anemia are considerable (Pasricha et al., 2013).
Fig. 2.3 shows the years lost to disability (DALYs) due to
anemia (Kassebaum et al., 2014). While the early stages
of iron deficiency are often asymptomatic, functional con-
sequences even in the absence of anemia include
increased maternal and perinatal mortality, low birth
weight, impaired cognitive performance, and poorer edu-
cational achievement as well as reduced work capacity
(Beard et al., 1996; Khan et al., 2006) with serious eco-
nomic impact on families and populations (Horton and
Ross, 2003). The median annual economic loss because
of IDA in 10 LMIC was estimated in 1994 US dollars at
$16.78 per capita, or 4% of gross domestic product
(Pasricha et al., 2013). Anemia, from all causes has been
estimated to lead to 17% reduced lower productivity in
heavy manual labor and an estimated 2.5% 4% loss of
earnings (Horton, 2006). This means there is an ongoing
and urgent need to deal with this possibility in LMIC
women, especially in pregnancy (Darnton-Hill and
Mkparu, 2015) and where populations experience a
greater infectious burden and systemic inflammation, both
of which can increase iron loss and concomitantly reduce
iron absorption and utilization (Prentice et al., 2007).
2.2.1.2 The gap remaining and the strategies to
reduce the gap
There are several strategies to reduce and/or treat iron
deficiency and iron-deficiency anemia: dietary modifica-
tion and diversification that aims to increase the content
and bioavailability of iron in the diet (Thompson and
Amoroso, 2011); preventive or intermittent iron supple-
mentation through tablets, syrups, or drops; fortification
with effective iron compounds of staple foods (typically
maize, soy, and wheat flour); and biofortification (WHO/
FAO et al., 2006). Such mass large-scale fortification of
staple foods aims to prevent the risk of developing iron
deficiency and treat preexisting iron-deficiency anemia
16 SECTION | I Need and Approach

FIGURE 2.2 Global estimates of the prevalence of anemia (WHO 2011). (A) In pregnant women aged 15 49 years, (B) In infants and children
aged 6 59 months. Taken with permission from the WHO Report “The global prevalence of anaemia in 2011” (WHO, 2015).

FIGURE 2.3 Total years lived with disability due to anemia per 10,000 population, by country (2010). Taken with permission from Kassebaum et al.
(2014).
 Prevalence, Causes, and Consequences of Micronutrient Deficiencies Chapter | 2
(Peña-Rosas et al., 2014). Iron fortification can be, and
usually is, accompanied by other micronutrients (such as
folic acid, vitamin B12, or vitamin C) to enhance the
effectiveness of the intervention (Zimmermann and
Hurrell, 2007). Mass targeted or market-driven food forti-
fication with iron is increasingly being used with various
other vehicles including soy sauce, fish sauce, salt, milk,
sugar, beverages, bouillon cubes, maize flour, and com-
plementary foods (WHO/FAO et al., 2006). Recent stud-
ies and a systematic review of iron fortification of foods
have found an association with increased hemoglobin,
improved iron status, and reduced anemia across popula-
tions (Gera et al., 2012) and the most recent study found
that anemia prevalence had in fact decreased significantly
in countries that fortify flour with micronutrients, com-
pared with countries that do not, and that countries that
had been fortifying for a longer time were more likely to
see reductions in anemia (Barkley et al., 2015).
Deworming in conjunction with other interventions, such
as malaria control interventions, is effective in some
situations in reducing anemia and in increasing the effi-
cacy of interventions that increase iron intakes
(Spottiswoode et al., 2012; Stoltzfus, 2011).
An earlier joint statement on anemia from WHO and
UNICEF emphasized an integrated approach consisting of
iron supplementation, iron fortification of food, treatment
of coexisting pathological conditions, dietary diversifica-
tion and improved nutrition, improved sanitation and
access to clean water, improved access to health care, and
nutritional education of consumers (WHO/SEARO,
2015). Nevertheless, there has been little progress—since
1995, the global prevalence in all groups has fallen only
slightly, e.g., the global prevalence of anemia fell by only
0.02 to 0.3 %/year between 1993 and 2013 (Branca et al.,
2014). WHO has set a 50% reduction of anemia in
women of reproductive age (from 2011 prevalence) as the
second global nutrition target for 2025 (WHO, 2012).
2.2.2 Iodine
Deficiency of iodine resulting in goiter has been described
since ancient times (Hetzel et al., 2004). The deficiency,
resulting in a reduction in the production of thyroid hor-
mone amongst other physiological effects, leads to a spec-
trum of iodine deficiency disorders (IDDs) including
goiter, intellectual impairments, growth retardation, neo-
natal hypothyroidism, and increased pregnancy loss and
infant mortality (Zimmermann and Boelaert, 2015). Prior
to the widespread salt iodization in LMIC, there were few
countries in the world where some degree of iodine defi-
ciency had not been a public health problem.
Considerable progress has been made but the problem
remains in many LMIC countries (and much of Eastern
Europe) as can be seen in Fig. 2.3 (Iodine Global
17
Network IGN, 2015a; Iodine Global Network IGN,
2015b; Aburto et al., 2014).
2.2.2.1 Health and economic consequences of
iodine deficiency
Iodine deficiency is the world’s single greatest cause of
preventable mental retardation. Deficiency is especially
damaging during the early stages of pregnancy and in early
childhood leading to, in its most severe form, cretinism,
stillbirth and miscarriage, and increased infant mortality
(Hetzel et al., 2004; Zimmermann and Boelaert, 2015).
Even mild deficiency can cause a significant loss of learning
ability ranging from around 8 up to 15 IQ points (Rohner
et al., 2014; Zimmermann and Boelaert, 2015; Bleichrodt
and Born, 1994; Christian et al., 2015). Iodine deficiency
consequently results in a loss of significant economic
productivity. It has been estimated by the World Bank that
each US dollar dedicated to IDD prevention would yield a
productivity gain of US$28 (Hetzel et al., 2004).
2.2.2.2 The gap remaining and the strategies to
reduce the gap
Tremendous progress has been made through salt fortifica-
tion with iodine over the last several decades—the propor-
tion of households in the developing world consuming
adequately-iodized salt has risen from less than 20% in
1990 to over 74% today (UNICEF, 2015) and the number
of countries classified as iodine deficient has fallen dra-
matically from 110 in 1990 to 25 in 2015 (Iodine Global
Network IGN, 2015). Despite this substantial progress,
iodine deficiency remains a persistent public health prob-
lem, affecting both industrialized and developing nations,
where the intake of iodine through iodized salt or alterna-
tive strategies is low or irregular (Pearce et al., 2013).
Currently 26% of LMIC households still do not consume
iodized salt (The World Bank, 2015) and twenty-five coun-
tries remain iodine-deficient (defined as median UIC
,100 µg/L) (seven moderately deficient and 18 are mildly
so)---none are currently considered as severely iodine-
deficient (Iodine Global Network IGN, 2015a,b) (Fig. 2.4).
These figures are currently being updated (Iodine Global
Network IGN, 2015a) (Gorstein personal communication).
Iodine deficiency remains a particular threat to the
health and development of some vulnerable populations
such as those with higher iodine requirements (weaning
infants, preschool children, and pregnant and lactating
women), and those “difficult-to-reach” due to restricted
geographical access to iodized salt or in countries in con-
flict situations. The IGN’s global scorecard for 2014 esti-
mates of “still-unprotected infants” exceeds 38 million.
While more information is available over the last few
years, data are still missing from 41 countries including
countries such as Congo, Iraq, Israel, and Syria (Iodine
18 SECTION | I Need and Approach
FIGURE 2.4 Global map of iodine nutrition. Taken with permission from the Iodine Global Network IGN (2015a,b).
Global Network IGN, 2015a). Where salt iodization alone
is not sufficient for control of iodine deficiency in vulner-
able populations, iodized oil supplementation can be a
feasible (often complementary) option for women of
reproductive age. Even in some more affluent countries,
iodine deficiency is reappearing in pregnant women
(Rohner et al., 2014). All alternative strategies to
Universal Salt Iodization (USI) however, are likely to be
more costly in delivering adequate iodine.
2.2.3 Folate and Neural Tube Defects
(NTDs)
Neural tube defects (NTD), which include anencephaly,
spina bifida, and encephalocele, are congenital malforma-
tions that arise during the structural development of the
neural tube, a process that is completed in 21 to 28 days
after conception (Blencowe et al., 2010). NTDs are con-
servatively estimated to have an incidence of .300,000
new cases a year resulting in 2.3 million DALYs while
exhibiting a social gradient with the most economically
disadvantaged populations in countries having the highest
incidence (Blencowe et al., 2010). The distinction is made
between folate, the naturally occurring vitamin, and folic
acid, the synthetic form most commonly used as a supple-
ment or fortificant. Folate is a water-soluble B vitamin
present in legumes, leafy green vegetables, and some
fruits (such as citrus fruits). In general dietary terms, on
average, usual folate intakes are often insufficient to
achieve a folate status associated with the lowest risk of
NTDs (McNulty and Scott, 2008). The bioavailability of
folic acid is approximately 70% higher than that of folate
naturally contained in foods, although there are wide var-
iations depending on the methodology used in the mea-
surement (McNulty and Pentieva, 2004).
2.2.3.1 Health and economic consequences of
folate deficiency
Clinical folate deficiency itself results in megaloblastic
anemia, the second most common cause of anemia during
pregnancy (Sifakis and Pharmakides, 2000). Folic acid
derivatives are essential for DNA synthesis, DNA methyl-
ation, cell division, and tissue growth with methylation
enabling proper gene expression and chromosome struc-
ture maintenance, all critical biological processes, and
especially for fetal development (Blom et al., 2006; Razin
and Kantor, 2005). Insufficient periconceptional folate is
also associated with a number of birth defects that may
relate to genetic and environmental factors operating
before conception or during early pregnancy (Safi et al.,
2012). Low levels of both folate and vitamin B12 (and
associated hyperhomocysteinemia) have been identified in
mothers of children with NTD (Yadav et al., 2015).
While increased maternal intake of folate and folic acid is
specifically associated with a decreased risk for NTDs,
folic acid supplementation does not have a clear effect on
other birth defects (De-Regil et al., 2010).
The health and economic consequences of folate defi-
ciency are not the same as the consequences of those
 Prevalence, Causes, and Consequences of Micronutrient Deficiencies Chapter | 2
suffering from neural tube and related defects, especially
as the latter specifically involves the affected individual,
his/her family, and the community; health system support
will be very different depending on the socioeconomic
conditions and capacity. Folate and the metabolically
related B-vitamins, vitamin B12 and riboflavin, have
received both increased scientific and public health inter-
est in recent years (McNulty and Scott, 2008) because
evidence is now recognizing other potential roles for
folate and/or related B-vitamins in protecting against car-
diovascular disease (especially stroke) (Refsum and
Smith, 2008), certain cancers, cognitive impairment, and
osteoporosis, beyond the well-established role in prevent-
ing NTDs, but any exact relationships remain to be con-
firmed (McLean et al., 2008).
2.2.3.2 The gap remaining and the strategies to
reduce the gap
Reviews of folate deficiency worldwide, including one
from the BOND Initiative (Bailey et al., 2015), have
highlighted the need for more population-based studies
specifically designed to assess folate status, consensus on
the best indicators for assessing folate status, and agree-
ment on the appropriate biomarker cut-off point to define
the severity of deficiency to gain a better understanding
of the magnitude of folate deficiency worldwide (McLean
et al., 2008; Bailey et al., 2015).
In an earlier WHO report (McLean et al., 2008), folate
and vitamin B12 status were most frequently assessed in
women of reproductive age (34 countries), and in all
adults (27 countries), respectively. No relationship
between vitamin concentrations and geographical distribu-
tion, level of development, or population groups could be
identified. Consequently, the estimation of the public
health gap for folate can only be measured by the number
of countries with no folic acid fortification of staples. The
Food Fortification Initiative estimates that currently 80
countries have introduced folic acid fortification legisla-
tion (Flour Fortification Initiative FFI, 2015). Besides
folic acid fortification, supplementation with folic acid is
internationally recommended to women from the moment
they are trying to conceive until 12 weeks of pregnancy
(WHO, 2012) but has had limited effectiveness. Another
option, also recommended by the WHO e-Library of
Evidence for Nutrition Actions (eLENA) (WHO, 2015),
is that women of reproductive age take weekly preventive
iron and folic acid supplements, especially in populations
where the prevalence of anemia is above 20%.
2.2.4 Vitamin A Deficiency
Relative poverty remains the predominant underlying
cause of vitamin A deficiency (VAD) as a public health
19
problem. Populations consuming diets of poor quality and
who have limited access to sources of more bioavailable,
but relatively expensive and so less accessible, retinol-
rich source foods, are particularly susceptible (Sommer
and West, 1996). Beta-carotene, a precursor to vitamin
A is generally found in plant sources and, while cheaper,
is much less bioavailable (Palmer et al., 2017;
Tanumihardjo, 2011). The 1995 2005 WHO estimates
classified 122 countries as having a moderate to severe
public health problem based on low serum retinol levels
(#0.70µmol/L) in preschool-age children (Fig. 2.5A);
while 88 countries were classified as having a problem of
moderate to severe public health significance with respect
to biochemical VAD in pregnant women (Fig. 2.5B)
(WHO, 2009). The most vulnerable are young children
and pregnant or lactating mothers (WHO, 2009), espe-
cially during the last trimester when demand by both the
unborn child and the mother is highest (WHO, 2015).
Low serum retinol concentration affects an estimated 190
million preschool-age children and 19.1 million pregnant
women globally. This corresponds to 33.3% of the
preschool-age population and 15.3% of pregnant women
in populations at risk of VAD, globally (WHO, 2009).
Africa and South-East Asia are the most affected by VAD
for both population groups (WHO, 2009). Remaining
challenges to more accurate estimations include more
recent national surveys, identifying the best biomarkers
and their relationship to coexisting infectious diseases,
and the body’s homeostatic mechanisms regulating vita-
min A in the body (Tanumihardjo, 2011).
2.2.4.1 Health and economic consequences of
vitamin A deficiency
Clinical conditions caused by VAD range from blindness
due to xerophthalmia (the leading cause of
preventable childhood blindness), anemia, and a weak-
ened host resistance to infection by childhood infectious
diseases, increasing their severity and increasing the risk
of mortality to young children by nearly a quarter
(Sommer and West, 1996). Poor diets, along with high
prevalence of infectious diseases and poor environmental
conditions, lead to low body stores of vitamin A that inad-
equately meet physiologic needs for supporting tissue
growth, normal metabolism, and resistance to infection
(Palmer et al., 2017; WHO, 2015; Tanumihardjo, 2011).
An estimated 250,000 to 500,000 vitamin A-deficient
children become blind every year, half of them dying
within 12 months of losing their sight (WHO, 2015).
Globally, night blindness (an early clinical sign of VAD)
is estimated to affect 5.2 million preschool-age children
(95% CI: 2.0 8.4 million) and 9.8 million pregnant
women (95% CI: 8.7 10.8 million).
20 SECTION | I Need and Approach
FIGURE 2.5 Category of public health significance of vitamin A deficiency (1995 2005). (A) In preschool-age children. (B) In pregnant women.
Taken with permission from the WHO (2009).
2.2.4.2 The gap remaining and the strategies to
reduce the gap
Overwhelmingly, it is the reduced resistance to infectious
disease that makes VAD such a devastating public health
problem and that has led to the global attention it has
received. Supplementation with high doses of retinol in
oil two to three times a year to children aged 6 59
months has been a major public health intervention and
has been the intervention of choice with considerable
funding implications (mainly from the Canadian
Government through the Micronutrient Initiative).
Nevertheless, because high dose supplementation in itself
does not lead to lasting improvement in vitamin A status,
most recommendations have noted the need for comple-
mentary actions such as improving diets, e.g., through
home gardening, often in female-headed households, and
addressing infectious diseases (Talukder et al., 2000).
This requires nutrition education to change dietary habits,
as well as providing better access to vitamin A or provita-
min A (beta-carotene)-rich foods where possible, but can
include most of the orange-fleshed fruits such as man-
goes, papaya, or vegetables (not least the biofortified
orange sweet potato) or dark green leafy vegetables.
Encouraging home gardening or local cooperatives to
grow such foods has had considerable success including
in empowerment of women in some settings such as
 Prevalence, Causes, and Consequences of Micronutrient Deficiencies Chapter | 2
Bangladesh and sweet potato biofortification in southeast
African countries (Palmer et al., 2017).
Although there has been a long history of vitamin A
fortification in margarine and milk in northern Europe
(Fletcher et al., 2004), fortification has only recently been
seen as an option for LMIC. There is current questioning
of the reliance on likely unsustainable national supple-
mentation programs (e.g., if the very few donors involved
stop supporting the intervention), and because many con-
sider a regular intake in smaller quantities, as fortification
could provide, is more physiological, and more effective
(Mason et al., 2014; Mason et al., 2015). Increasing the
dietary intake of vitamin A through fortification of a sta-
ple food or condiment with vitamin A has been the pri-
mary strategy for reducing VAD in Central and South
America, where sugar began to be fortified with vitamin
A three decades ago (WHO/FAO et al., 2006; Dary and
Mora, 2002; Mora et al., 2000). Since the fortification of
sugar with vitamin A in 1974, It is estimated that now
only a very few of the poorest families do not have ade-
quate vitamin A intake (Dary and Mora, 2002; Dwyer
et al., 2015). Fortifying with vitamin A is gaining
momentum as increasing numbers of other potentially for-
tifiable foods such as edible oils become centrally pro-
duced or processed under controlled conditions and
penetrate broader socioeconomic markets in LMIC.
2.2.5 Zinc
Zinc is essential for multiple aspects of metabolism and
important for cellular growth, cellular differentiation, and
metabolism, with deficiency limiting childhood growth
and decreasing resistance to infections (King, 2011).
While it is suspected that there is a great deal of zinc defi-
ciency, biomarkers to assess this are problematic (de
Benoist et al., 2007; King et al., 2016). Physiologic signs
of zinc depletion are linked with diverse biochemical
functions rather than with a specific function, a situation
that does not lend itself to the identification of specific
biomarkers of zinc nutrition (King, 2011). Although more
national surveys now include the assessment of plasma
zinc concentration, there are still insufficient data on the
global prevalence of zinc deficiency. Consequently there
has been a use of surrogate markers such as growth, using
plasma zinc concentration and/or estimated dietary zinc
intake in countries identified at high risk of zinc defi-
ciency based on a high stunting prevalence or high preva-
lence of estimated low dietary zinc availability (de
Benoist et al., 2007).
Wessells et al. (2012) estimated the prevalence of
inadequate zinc intake based on the apparent absorbable
zinc content of the national food supplies as derived from
national food balance sheet data obtained from the FAO.
A “best-estimate” model, comprised of zinc and phytate
21
data from a composite nutrient database and the
International Zinc Nutrition Consultative Group
(IZiNCG) physiological requirements for absorbed zinc
(de Benoist et al., 2007; International Zinc Nutrition
Consultative Group IZiNCG, 2010), estimated the global
prevalence of inadequate zinc intake to be 17.3%
(Wessells et al., 2012) depending on which methodologi-
cal assumptions were applied. The estimate used here of
global stunting is thought to somewhat reflect zinc defi-
ciency while understanding factors such as inadequate
protein intakes, concomitant infectious disease, etc., also
contribute to stunting (Fig. 2.6). The regional prevalence
of inadequate intake is estimated to range from 6% to 7%
in high-income regions and Latin America and the
Caribbean to 30% in South Asia. WHO (2015). The
WHO estimates approximately 165 million children under
5 years of age are stunted (height-for-age , 2 SD
below the WHO Child Growth Standards median), with
the vast majority living in Africa and Asia.
2.2.5.1 Health and economic consequences of
zinc deficiency
Given the association of zinc deficiency and growth stunt-
ing, zinc deficiency feasibly effects stunting, and all the
economic and health consequences that lead from stunting.
As with other micronutrient deficiencies, zinc deficiency is
more likely during pregnancy due to increased nutrient
requirements of the mother and the developing fetus.
Although there is good evidence of the efficacy of zinc in
treatment of diarrhea, and some studies have shown mor-
tality, morbidity, and growth benefits, there remain a num-
ber of information gaps as to the size of the effects and the
optimal pattern of intervention (de Benoist et al., 2007).
The consequences of the population zinc gap cannot there-
fore be accurately known (King et al., 2016). Zinc as an
incremental cost in diarrhea management however is very
cost-effective, with an average cost of US$73 per DALY
gained and US$2,100 per death averted (International Zinc
Nutrition Consultative Group IZiNCG, 2010).
2.2.5.2 The gap remaining and the strategies to
reduce the zinc gap
The available evidence suggests that zinc supplementation
during pregnancy may help to reduce preterm births in
low-income settings, but does not prevent other subopti-
mal pregnancy outcomes including low-birth-weight or
preeclampsia (King et al., 2016). Currently there are no
estimates for the effectiveness of zinc coming into the
diet through fortification. Supplements taken separately
from food result in a rapid increase in plasma concentra-
tions, whereas consuming a food fortified with zinc will
have a more gradual effect on blood concentrations
because of the presence of the food matrix (Brown et al.,
22 SECTION | I Need and Approach
2007). The available evidence is inconsistent, but suggests
that zinc supplementation may help to improve linear
growth of children under 5 years of age (WHO, 2015).
WHO has adopted an interim consensus statement on for-
tification of wheat and maize flour with a variety of
micronutrients, including zinc (WHO, 2015; King et al.,
2016). In the absence of more definitive recommenda-
tions, some countries such as Fiji have gone ahead with
including zinc as a fortificant (Flour Fortification
Initiative FFI, 2015).
2.2.6 Other Micronutrients
As information in different populations becomes more
available, other micronutrients, at least in some subpopu-
lations, are likely to become of greater public health inter-
est. Folate and zinc both became widespread public health
targets only over the last decade or so. There is now
increasing evidence that vitamins B12, D, and E, and cal-
cium and selenium, and perhaps others, should be
assessed for their public health significance and whether
fortification is an option. Vitamin B12 deficiency is quite
consistently thought to be underrated as a problem (Allen
et al., 2010), particularly in vegetarian populations. Not
all micronutrient deficiencies are however, necessarily
suitable for addressing through fortification (Fletcher
et al., 2004).
2.2.6.1 Vitamin B12
The B vitamins as a group have been used as fortificants,
through yeast initially, since early fortification programs,
FIGURE 2.6 Prevalence of nutri-
tional stunting in children under 5
years of age. Taken with permis-
sion from International Zinc
Nutrition Consultative Group
(IZiNCG, 2010).
when niacin was being used to help eliminate pellagra as
a public health problem in endemic areas (Park et al.,
2000). Especially in terms of women’s general health,
besides the established concern with megaloblastic ane-
mia and neurological damage, there appears to be other
good reasons to increase vitamin B12 and other B vitamin
intakes. It has been shown, e.g., that vitamin B12 status
differs among pregnant and lactating women (PLW) com-
pared to non-PLW and that this appears to reflect the
enhanced vitamin B12 supply to the fetus (Bae et al.,
2015). Large surveys in the USA and the UK, have found
that vitamin B12 deficiency is not uncommon and the
prevalence increases with age (Allen and Peerson, 2009).
In the UK, approximately 6% of $ 60 year olds were
vitamin B12 deficient (plasma vitamin B12 ,48 pmol/L),
with almost 20% having marginal status in later life
(Allen, 2009). In LMIC, vitamin B12 deficiency is even
more common, starting in early life and persisting to old
age, due to a low consumption of animal-source foods
(Allen, 2009). The potential population thought to be at
risk, is expanded by a recent study showing that vitamin
B12 deficiency in children in Colombia was associated
with grade repetition and school absenteeism, independent
of folate, iron, zinc, or vitamin A status biomarkers
(Duong et al., 2015). There is some indication that high
rates of low or marginal vitamin B12 status remain in
most locations and across population groups in Latin
America and the Caribbean (Brito et al., 2015).
In older persons, food-bound cobalamin malabsorption
becomes the predominant cause of vitamin B12 deficiency,
at least in part due to gastric atrophy, but importantly, it is
likely that most elderly can absorb the vitamin from
 Prevalence, Causes, and Consequences of Micronutrient Deficiencies Chapter | 2
fortified food (Allen and Peerson, 2009). While fortifica-
tion of flour with vitamin B12 is therefore likely to improve
the status of most persons with low stores of this vitamin,
intervention studies are still needed to assess efficacy and
functional benefits of increasing intake of the amounts
likely to be consumed in flour, including in elderly persons
with varying degrees of gastric atrophy (Allen, 2009). It
has also been suggested that pregnant and lactating women
may benefit from intakes exceeding current recommenda-
tions (Bae et al., 2015), particularly so in some populations
that have low intakes such as largely vegetarian popula-
tions, and the authors suggest that fortification may pro-
vide this (Bae et al., 2015).
In countries with mandatory fortification of cereal
flour with folic acid for the prevention of NTDs, folate
deficiency no longer appears to be a public health prob-
lem (prevalence ,5%). Adding vitamin B12 as a fortifi-
cant along with folic acid has been suggested as a
strategy in areas where vitamin B12 deficiency is an estab-
lished concern (Allen et al., 2010). The prevalence of low
serum vitamin B12 status (in the absence of anemia or
macrocytosis) does not appear to increase after mandatory
folic acid fortification (Qi et al., 2014). In LMIC, flour
fortification would potentially improve vitamin B12 status
in a much larger proportion of the population because of
low usual intake of the vitamin in ASFs (animal-source
foods) (Allen, 2009; Allen et al., 2017).
Deficiencies of some of the other B vitamins, while not
uncommon in LMIC, are rarely life-threatening (except thi-
amin deficiency in some circumstances). Nevertheless,
because of their role in deficiency diseases such as pellagra
(niacin) and anemia (riboflavin and other B vitamins) as
well as superficial skin and mouth lesions, since the 1940s,
thiamin, riboflavin, and niacin have been included along
with iron and folic acid in the fortification of flour and
cereal products (Eggersdorfer et al., 2016). Riboflavin defi-
ciency is known to be endemic in many LMIC (Powers,
2003). There is also evidence that riboflavin status is gen-
erally low in the UK population and other affluent coun-
tries, and particularly so in the elderly and in younger
women (McNulty and Scott, 2008). The endemicity of B
vitamins and probable interaction with other micronutrients
(Powers, 2003) means that they are also added to fortified
complementary feeding supplementary foods (thiamin,
riboflavin, niacin, vitamin B6, vitamin B12, along with
folic acid, other micronutrients, and the macronutrients of
energy, protein, carbohydrate, and fat) (Eggersdorfer et al.,
2016) when treating acute malnutrition in children.
2.2.6.2 Vitamin D
Similarly, vitamin D has provoked a great deal of
increased interest and attention over the last decade or so
(Dror and Allen, 2010; Palacios and Gonzalez, 2013).
23
Historically, vitamin D has been associated with rickets, a
disease now largely under control (Palacios and
Gonzalez, 2013). However, there are periodic reports of
immigrants to northern Europe, especially if dark-skinned
and infant swaddling is practised, being deficient
(Palacios and Gonzalez, 2013; Wahl et al., 2012;
Thandrayen and Pettifor, 2012). Maternal vitamin D defi-
ciency, variously quoted as having a prevalence of 8% to
100% depending on the country of residence and the defi-
nitions of vitamin D deficiency, predisposes to low vita-
min D stores in the newborn and so increases the risk of
infantile rickets because the mother is the only source of
vitamin D during pregnancy (Thandrayen and Pettifor,
2012). Global estimates of vitamin D deficiency are
scarce and appropriate biomarkers and their cut-off points
are uncertain (Hossein-nezhad and Holick, 2013). A 2011
systematic review on vitamin D deficiency concludes that
there is some indication that vitamin D insufficiency may
be a public health problem in Latin America and the
Caribbean, but the exact magnitude is currently unknown
(Brito et al., 2013). The only country with a nationally
representative sample was Mexico, which found 24%,
10%, 8%, and 10% prevalence rates of vitamin D insuffi-
ciency (25-hydroxyvitamin D , 50 nmol/L) in preschoo-
lers, schoolchildren, adolescents, and adults, respectively
(Brito et al., 2013). More information on the prevalence
of vitamin D deficiency can be found in Chapter 27.
Vitamin D deficiency and rickets were controlled in
affluent countries after the Second World War by a com-
bination of vitamin D (and vitamin A) being added to
milk and margarine, better diets in general, and
improved living conditions including less industrial pol-
lution (Park et al., 2000; Rasmussen et al., 2006).
However, whether vitamin D deficiency is a worldwide
health problem is not really known because of the
unknown extent of effects in a wide range of acute and
chronic diseases beyond musculoskeletal effects
(Palacios and Gonzalez, 2013; Wahl et al., 2012;
Hossein-nezhad and Holick, 2013). Such unproven possi-
bilities include increased risks of type 1 diabetes melli-
tus, cardiovascular disease, certain cancers, cognitive
decline, depression, pregnancy complications, autoim-
munity, allergy, and even frailty (Hossein-nezhad and
Holick, 2013; Hossein-nezhad and Holick, 2012; Holick,
2012; Holick, 2012; Smit et al., 2012).
2.2.6.3 Vitamin E
Besides being a potent antioxidant, vitamin E is involved
in a range of physiological processes including immune
function, control of inflammation, regulation of gene
expression, and cognitive performance (Dror and Allen,
2011). Marginal intakes of vitamin E are relatively com-
mon in the USA but there is little information globally
24 SECTION | I Need and Approach
(Dror and Allen, 2011). It is suggested that LMIC popula-
tions are at greater risk of deficiency through limited
intakes of the vitamin from the diet and a higher preva-
lence of oxidative stressors such as malaria and HIV
which increase its depletion (Dror and Allen, 2011). Data
from NHANES 2003 2006 indicate that the average die-
tary intake of alpha-tocopherol from food (including
enriched and fortified sources) among US Americans two
years and older was 6.9 mg/day (Fulgoni et al., 2011)
which is well below the current Recommended Dietary
Allowance (RDA) of 15 mg/day. At this level of dietary
intake, although more than 90% of Americans would
apparently not be meeting daily dietary recommendations
for vitamin E (Fulgoni et al., 2011), fortification with
vitamin E is likely, at least in more affluent countries, to
continue to be voluntary in commercially sold retail
foods. Estimated figures of deficiency for LMIC are not
currently available but as noted above, are likely to be
even higher (Dror and Allen, 2011). Issues with biomar-
kers and cut-off points currently mitigate against more
accurate assessments.
2.2.6.4 Selenium
Although there are well-recognized areas globally, such
as Australia, China, Finland, New Zealand, and Russia,
where the soils are selenium-deficient, it appears that
other factors need to be present to aggravate the defi-
ciency before a clinical syndrome such as Kaishin-Beck’s
disease or Keshan disease is manifest. Selenium defi-
ciency is known to exacerbate iodine deficiency increas-
ing the chance of cretinism (Rasmussen et al., 2011).
China has used fortification of salt plus other measures to
address the disease in its northwest but it seems unlikely
this would become more widely used (Ning et al., 2015),
although Finland does “fortify” its fertilizers.
2.3 CONCLUSIONS
In both LMIC and more affluent economies, the risk of a
wide range of conditions due to micronutrient deficiencies
remains high, especially in women and children, adoles-
cents, and the elderly. The risks are increased by concom-
itant higher prevalence of infectious diseases and by poor
socioeconomic conditions. The nutritional status and
resulting health of both individuals and societies exist as
the outcomes of immediate, underlying and basic social,
political, and cultural factors (UNICEF, 1990; Black,
2003; Ruel and Alderman, 2013), as well genetic and
environmental, even probably ancestral, factors (Hardikar
et al., 2015).
Not surprisingly, the most effective interventions,
when scaled-up, are often those that address more than
one of these factors and use different mixes of
interventions depending on the problem they are addres-
sing and the national situation and resources (Bryce et al.,
2008). Programs that aim to improve dietary quality and
diversity and socioeconomic conditions, along with large-
scale supplementation of micronutrients when appropri-
ate, need also to address more widely both “nutrition-spe-
cific” and “nutrition-sensitive” interventions (Bhutta
et al., 2013; Ruel and Alderman, 2013). While fortifica-
tion is often seen as one of the simpler interventions, it is
now recognized that all the interventions have their own
complexities and advantages and should address local
conditions and resources and capacities. Somewhat disap-
pointingly perhaps, the new Sustainable Development
Goals (SDGs) have only one goal directly targeting nutri-
tion (“Goal 2: End hunger, achieve food security and
improved nutrition and promote sustainable agriculture”),
but it is hard to see how this goal would be achieved
without the contribution of fortification in helping to
eliminate micronutrient deficiencies. Encouragingly, the
United Nations General Assembly has proclaimed a UN
Decade of Action on Nutrition (from 2016 to 2025) that
aims to intensify “action to end hunger and eradicate mal-
nutrition worldwide, and ensure universal access to
healthier and more sustainable diets—for all people, who-
ever they are and wherever they live” (UN FAO/WHO,
2016-2025).
Historically, micronutrient deficiencies have been con-
trolled, in some cases largely eliminated, by improving
social conditions, disease control, and improved diets, and
by programs of fortification, supplementation, and other
nutrition-sensitive interventions such as those addressing
inequities and gender imbalances (Darnton-Hill et al.,
2017). Especially for single micronutrient deficiencies,
large-scale fortification has largely, but not completely,
eliminated such deficiency diseases as pellagra and rick-
ets, and largely controlled others such as the iodine defi-
ciency disorders. Supplementation programs have been
important for vitamin A deficiency which is also being
increasingly addressed by fortification of fats and oils and
condiments. Anemia levels have been largely left
unchanged in LMIC despite extensive national programs
of supplementation in pregnancy with iron and folic
acid—largely because of poor logistics, knowledge of
both health workers and the population, and side effects
(Mason et al., 2013). But as will be seen in other chapters,
there is encouraging evidence in increasing effectiveness
with improved fortificants and increasing reach (European
Commission, 2017; Darnton-Hill et al., 2015).
Fortification with folic acid, e.g., has had an impressive
impact in reducing neural tube defects (De-Regil et al.,
2010) as has iodization of salt in reducing iodine defi-
ciency disorders (Iodine Global Network IGN, 2015a).
Increasingly, staple cereals, other foods, including
complementary foods for young children, are being
 Prevalence, Causes, and Consequences of Micronutrient Deficiencies Chapter | 2
fortified and available in most markets, both affluent and
in emerging economies. Nevertheless, an estimated 2 bil-
lion people remain deficient, including those living in
more affluent settings, with women, adolescents, and chil-
dren being most at risk. Deficiencies, such as high levels
of anemia, continue to exist, not least in the growing num-
bers of elderly people, while iodine deficiency is showing
a worrying increase in young pregnant women in many
countries. Addressing these still current deficiencies
through fortification, as the many successes seen in the
remaining chapters demonstrate, along with identifying
some continuing barriers, are the main challenges ahead.
The global beneficial health and economic consequences
of reducing micronutrient deficiencies will be considerable.
REFERENCES
Aburto, N.J., et al., 2014. Effects and safety of salt iodisation to prevent
iodine deficiency disorders: a systematic review with meta-analyses.
WHO eLibrary of Evidence for Nutrition Actions (eLENA). World
Health Organization, Geneva.
Alderman, H., Horton, S., 2007. The economics of addressing nutritional
anemia. In: Kraemer, K., Zimmermann, M.B. (Eds.), Nutritional
anemia. Sight and Life Press, Basel, pp. 19 36.
Allen, L.H., 2005. Multiple micronutrients in pregnancy and lactation:
an overview. Am J Clin Nutr 81 (5), S1206 S1212.
Allen, L.H., 2009. How common is vitamin B-12 deficiency? Am J Clin
Nutr 89 (2), S693 S696.
Allen, L.H., Peerson, J.M., 2009. Impact of multiple micronutrient versus
iron-folic acid supplements on maternal anemia and micronutrient
status in pregnancy. Food Nutr Bull 30 (4 Suppl), S527 S532.
Allen, L.H., Rosenberg, I.H., Oakley, G.P., Omenn, G.S., 2010.
Considering the case for vitamin B12 fortification of flour. Food
Nutr Bull 31, S36 S46.
Allen L.H., Miller J.W., de Groot L.C.P.G.M., Rosenberg I.H., Smith D.,
Refsum H., et al. Biomarkers ofNutrition for Development (BOND):
vitamin B12 review. J Nutr NUTRITION/2017/254599. Version1.
2017.
Bae, S., et al., 2015. Vitamin B-12 Status Differs among Pregnant,
Lactating, and Control Women with Equivalent Nutrient Intakes. J
Nutr 145 (7), 1507 1514.
Bailey, L.B., Stover, P.J., McNulty, H., Fenech, M.F., Gregory III, J.F.,
Mills, J.L., et al., 2015. Biomarkers of Nutrition for Development -
Folate Review. Supplement: Biomarkers of Nutrition for
Development (BOND) Expert Panel Reviews, Part 2. J Nutr.
Available from: https://doi.org/10.3945/jn.114.206599 published
ahead of print on June 3, 2015 as.
Bailey, R.L., West, K.P., Black, R.E., 2015. The epidemiology of global
micronutrient deficiencies. Ann Nutr Metab 66, 22 33.
Barkley, J.S., Wheeler, K.S., Pachon, H., 2015. Anaemia prevalence
may be reduced among countries that fortify flour. Br J Nutr 1 9.
Barros, A.J., et al., 2015. Equity in maternal, newborn, and child health
interventions in Countdown to 2015: a retrospective review of sur-
vey data from 54 countries. Lancet 379 (9822), 1225 1233.
Beard, J.L., Dawson, H., Pinero, D.J., 1996. Iron metabolism: a compre-
hensive review. Nutr Rev 54 (10), 295 317.
25
Bhutta, Z.A., et al., 2013. Evidence-based interventions for improvement
of maternal and child nutrition: what can be done and at what cost?
Lancet 382 (9890), 452 477.
Bhutta, Z.A., Haider, B.A., 2009. Prenatal micronutrient supplementa-
tion: are we there yet? CMAJ 180 (12), 1188 1189.
Black, R., 2003. Micronutrient deficiency--an underlying cause of mor-
bidity and mortality. Bull World Health Organ 81 (2), 79.
Black, R.E., et al., 2013. Maternal and child undernutrition and over-
weight in low-income and middle-income countries. Lancet 382
(9890), 427 451.
Bleichrodt, N., Born, M.P., 1994. A metaanalysis of research on iodine
and its relationship to cognitive development. In: Stanbury, J.B.
(Ed.), The damaged brain of iodine deficiency. Cognizant
Communication Corporation, New York.
Blencowe, H., et al., 2010. Folic acid to reduce neonatal mortality from
neural tube disorders. Int J Epidemiol 39 (Suppl 1), i110 i121.
Blom, H.J., et al., 2006. Neural tube defects and folate: case far from
closed. Nat Rev Neurosci 7 (9), 724 731.
Boerma, J.T., et al., 2008. Mind the gap: equity and trends in coverage
of maternal, newborn, and child health services in 54 Countdown
countries. Lancet 371 (9620), 1259 1267.
Branca, F., Mahy, L., Mustafa, T.S., 2014. The lack of progress in reduc-
ing anaemia among women: the inconvenient truth. Bull World
Health Organ 92 (4), 231.
Brito, A., et al., 2013. Less than adequate vitamin D status and intake in
Latin America and the Caribbean: a problem of unknown magnitude.
Food Nutr Bull 34 (1), 52 64.
Brito, A., et al., 2015. Folate and Vitamin B12 Status in Latin America
and the Caribbean: An Update. Food Nutr Bull 36 (Suppl 2),
S109 S118.
Brown, K.H., et al., 2007. Comparison of the effects of zinc delivered in
a fortified food or a liquid supplement on the growth, morbidity, and
plasma zinc concentrations of young Peruvian children. Am J Clin
Nutr 85 (2), 538 547.
Bryce, J., et al., 2008. Maternal and child undernutrition: effective action
at national level. Lancet 371 (9611), 510 526.
Christian, P., et al., 2015. Nutrition and maternal, neonatal, and child
health. Semin Perinatol 39 (5), 361 372.
Darnton-Hill, I., 2012. Global burden and significance of multiple micro-
nutrient deficiencies in pregnancy. In: Bhutta, Z.A., Hurrell, R.F.,
Rosenberg, I.H. (Eds.), Meeting Micronutrient Requirements for
Health and Development; Nestlé Nutrition Institute Workshop
Series, Vol 70. Karger, Basel, Switzerland, pp. 49 60.
Darnton-Hill, I., et al., 2005. Micronutrient deficiencies and
gender: social and economic costs. Am J Clin Nutr 81 (5),
S1198 S1205.
Darnton-Hill, I., Mkparu, U.C., 2015. Micronutrients in pregnancy in
low- and middle-income countries. Nutrients 7 (3), 1744 1768.
Darnton-Hill I., Friesen V., Neufeld L., Garrett G.S. Part A. Event pro-
ceedings. in The #FutureFortified Global Summit on Food
Fortification. 2015 (Held in Naura Springs Hotel, Arusha, the
United Republic of Tanzania September 9-11, 2015). Micronutrient
Forum/Government of Tanzania/Sight andLife/GAIN 2016.
Darnton-Hill, I., Neufeld, L., Vossenaar, M., Osendarp, S., Martinez, H.,
2017. On behalf of the Micronutrient Forum. Large-scale food forti-
fication: an overview of trends and challenges in Low and Middle-
Income Countries in 2017. Micronutrient Forum. Available from:
www.mnf.org.
26 SECTION | I Need and Approach
Dary, O., Mora, J.O., 2002. Food fortification to reduce vitamin A defi-
ciency: International Vitamin A Consultative Group recommenda-
tions. J Nutr 132 (9 Suppl), S2927 S2933.
de Benoist, B., et al., 2007. Conclusions of the Joint WHO/UNICEF/
IAEA/IZiNCG Interagency Meeting on Zinc Status Indicators. Food
Nutr Bull 28 (3 Suppl), S480 S484.
De-Regil, L.M., et al., 2010. Effects and safety of periconceptional folate
supplementation for preventing birth defects. Cochrane Database
Syst Rev (10), CD007950.
Dror, D.K., Allen, L.H. Nutrition Reviews. Vitamin D inadequacy in preg-
nancy: biology, outcomes, and interventions. 2010;68(8):465 77.
Dror, D.K., Allen, L.H., 2011. Vitamin E deficiency in developing coun-
tries. Food Nutr Bull 32, 124 143.
Duong, M.C., et al., 2015. Vitamin B-12 Deficiency in Children Is
Associated with Grade Repetition and School Absenteeism,
Independent of Folate, Iron, Zinc, or Vitamin A Status Biomarkers.
J Nutr 145 (7), 1541 1548.
Dwyer, J.T., et al., 2015. Fortification and health: challenges and oppor-
tunities. Adv Nutr 6 (1), 124 131.
Eggersdorfer, M., Kraemer, K., Cordaro, J.B., Fanzo, J., Gibney, M.,
Kennedy, E. (Eds.), 2016. Good nutrition: perspectives for the 21st
century. Karger, Basel; New York.
European Commission. Food Fortification Global Mapping Study 2016.
Prepared by Landell Mills and the Global Alliance for Improved
Nutrition for the European Commission. By Hoogendoorn A,
Luthringer C, Parvanta I, Garrett G. GAIN:Geneva 2017.
FAO, 2011. In: Thompson, B., Amoroso, L. (Eds.), Combatting micronu-
trient deficiencies: food-based approaches. Food and Agricultural
Organization of the United Nations & CABI, Rome.
FAO/WHO. Second International Conference on Nutrition. Rome, 19-21
November 2014. Conference Outcome Document: Rome Declaration
on Nutrition. 2014 [cited May2015]; Available from: http://www.
fao.org/3/a-ml542e.pdf.
Fletcher, R.J., Bell, I.P., Lambert, J.P., 2004. Public health aspects of
food fortification: a question of balance. Proc Nutr Soc 63 (4),
605 614.
Flour Fortification Initiative (FFI). Global Progress. 2015 [cited August
2015]; Available from: http://ffinetwork.org/global_progress/index.
php.
Fulgoni III, V.L., et al., 2011. Foods, fortificants, and supplements:
Where do Americans get their nutrients? J Nutr 141 (10),
1847 1854.
Gera, T., Sachdev, H.S., Boy, E., 2012. Effect of iron-fortified foods on
hematologic and biological outcomes: systematic review of random-
ized controlled trials. Am J Clin Nutr 96 (2), 309 324.
Goldenberg, R.L., McClure, E.M., 2012. Disparities in interventions for
child and maternal mortality. Lancet 379 (9822), 1178 1180.
Hardikar, A.A., et al., 2015. Multigenerational Undernutrition Increases
Susceptibility to Obesity and Diabetes that Is Not Reversed after
Dietary Recuperation. Cell Metab 22 (2), 312 319.
Hetzel, B.S., et al., 2004. Towards the global elimination of brain dam-
age due to iodine deficiency. Oxford University Press, New Delhi.
Holick, M.F., 2012. Vitamin D: extraskeletal health. Rheum Dis Clin
North Am 38 (1), 141 160.
Holick, M.F., 2012. Nutrition: D-iabetes and D-eath D-efying vitamin D.
Nat Rev Endocrinol 8 (7), 388 390.
Horton, S., 2006. The economics of food fortification. J Nutr 136 (4),
1068 1071.
Horton, S., Ross, J., 2003. The economics of iron deficiency. Food
Policy 28 (1), 51 75.
Horton, S., Alderman, H., Rivera, J., 2008. Copenhagen consensus 2008.
Malnutrition and hunger. Copenhagen Consensus Center.
Hossein-nezhad, A., Holick, M.F., 2012. Optimize dietary intake of vita-
min D: an epigenetic perspective. Curr Opin Clin Nutr Metab Care
15 (6), 567 579.
Hossein-nezhad, A., Holick, M.F., 2013. Vitamin D for health: a global
perspective. Mayo Clin Proc 88 (7), 720 755.
International Zinc Nutrition Consultative Group (IZiNCG). Prevalence
of nutritional stunting in children under 5 years of age. 2010 [cited
May2015]; Available from: http://izincg.org/news/stunting.
Iodine Global Network (IGN), 2015a. Global Scorecard 2014: Number
of iodine deficient countries more than halved in past decade. IDD
Newsletter 43 (1), 5 7.
Iodine Global Network (IGN). Global map of iodine nutrition. 2015b
[cited 12 August 2015]; Available from: http://ign.org/p142000429.
html.
Kassebaum, N.J., et al., 2014. A systematic analysis of global anemia
burden from 1990 to 2010. Blood 123 (5), 615 624.
Khan, K.S., et al., 2006. WHO analysis of causes of maternal death: a
systematic review. Lancet 367 (9516), 1066 1074.
King, J.C., 2011. Zinc: an essential but elusive nutrient. Am J Clin Nutr
94 (2), S679 S684.
King, J.C., et al., 2016. Biomarkers of Nutrition for Development
(BOND)-Zinc Review. J Nutr.
Lynch, S., 2012. Discussion on iron. Nestle Nutr Inst Workshop Ser 70,
128 133.
March of Dimes, 2006. In: Christianson, A., Howson, C.P., Modell, B.
(Eds.), Global report on birth defects: The hidden toll of dying and
disabled children. March of Dimes Birth Defects Foundation, New
York.
Martorell, R., et al., 2015. Effectiveness evaluation of the food fortifica-
tion program of Costa Rica: impact on anemia prevalence and hemo-
globin concentrations in women and children. Am J Clin Nutr 101
(1), 210 217.
Mason, J., et al., 2013. Reduction of anaemia. Lancet Glob Health 1 (1),
e4 e6.
Mason, J., et al., 2015. Vitamin A policies need rethinking. Int J
Epidemiol 44 (1), 283 292.
Mason, J.B., et al., 2014. The first 500 days of life: policies to support
maternal nutrition. Glob Health Action 7, 23623.
McLean, E., de Benoist, B., Allen, L.H., 2008. Review of the magnitude
of folate and vitamin B12 deficiencies worldwide. Food Nutr Bull
29 (1 Suppl), S38 S51.
McLean, E., et al., 2009. Worldwide prevalence of anaemia, WHO
Vitamin and Mineral Nutrition Information System, 1993-2005.
Public Health Nutr 12 (4), 444 454.
McNulty, H., Pentieva, K., 2004. Folate bioavailability. Proc Nutr Soc
63 (4), 529 536.
McNulty, H., Scott, J.M., 2008. Intake and status of folate and related B-
vitamins: considerations and challenges in achieving optimal status.
Br J Nutr 99 (Suppl 3), S48 S54.
Micronutrient Initiative, et al., Investing in the future: a united call to
action on vitamin and mineral deficiencies. Global Report 2009.
2009, Micronutrient Initiative: Toronto.
Mora, J.O., et al., Vitamin A Sugar Fortification in Central America
Experience and Lessons Learned. 2000, MOST Project:USAID.
 Prevalence, Causes, and Consequences of Micronutrient Deficiencies Chapter | 2
Muthayya, S., Rah, J.H., Sugimoto, J.D., Roos, F.F., Kraemer, K., Black,
R.E., 2013. The Global Hidden Hunger Indices and Maps: An
Advocacy Tool for Action. PLOS ONE. Published online.
Ning, Y., et al., 2015. Is It the Appropriate Time to Stop Applying
Selenium Enriched Salt in Kashin-Beck Disease Areas in China?
Nutrients 7 (8), 6195 6212.
Palacios, C., Gonzalez, L., 2013. Is vitamin D deficiency a major global
public health problem? J Steroid Biochem Mol Biol 144 Pt A,
138 145.
Palmer, A., I. Darnton-Hill, and K.W.J. West, Vitamin A Deficiency, in
Nutrition and Health in a Developing World, D. Pee, Editor. 2017:
In press.
Park, Y.K., et al., 2000. Effectiveness of food fortification in the
United States: the case of pellagra. Am J Public Health 90 (5),
727 738.
Pasricha, S.R., et al., 2013. Control of iron deficiency anemia in low-
and middle-income countries. Blood 121 (14), 2607 2617.
Pearce, E.N., Andersson, M., Zimmermann, M.B., 2013. Global iodine
nutrition: Where do we stand in 2013? Thyroid 23 (5), 523 528.
Peña-Rosas, J.P., et al., 2014. Wheat flour fortification with iron for
reducing anaemia and improving iron status in populations.
Cochrane Database Syst Rev. John Wiley & Sons, Ltd.
Pena-Rosas, J.P., et al., 2015. Daily oral iron supplementation during
pregnancy. Cochrane Database Syst Rev 12, CD004736.
Petry, N., et al., 2016. The Proportion of Anemia Associated with Iron
Deficiency in Low, Medium, and High Human Development
Index Countries: A Systematic Analysis of National Surveys.
Nutrients 8 (11).
Powers, H.J., 2003. Riboflavin (vitamin B-2) and health. Am J Clin Nutr
77, 1352 1360.
Prentice, A.M., et al., 2007. Iron metabolism and malaria. Food Nutr
Bull 28 (4 Suppl), S524 S539.
Qi, Y.P., et al., 2014. The prevalence of low serum vitamin B-12 status
in the absence of anemia or macrocytosis did not increase among
older U.S. adults after mandatory folic acid fortification. J Nutr 144
(2), 170 176.
Rasmussen, L.B., et al., 2011. Selenium status, thyroid volume, and mul-
tiple nodule formation in an area with mild iodine deficiency. Eur J
Endocrinol 164 (4), 585 590.
Rasmussen, S.E., et al., 2006. A safe strategy for addition of vitamins
and minerals to foods. Eur J Nutr 45, 123 135.
Razin, A., Kantor, B., 2005. DNA methylation in epigenetic control of
gene expression. Prog Mol Subcell Biol 38, 151 167.
Refsum, H., Smith, A.D., 2008. Are we ready for mandatory fortification
with vitamin B-12? Am J Clin Nutr 88 (2), 253 254.
Rohner, F., et al., 2014. Biomarkers of nutrition for development--iodine
review. J Nutr 144 (8), S1322 S1342.
Rowe, L.A., Dodson, D.M., 2012. A knowledge-to-action approach to
food fortification: guiding principles for the design of fortification
programs as a means of effectively addressing micronutrient malnu-
trition. Health 4, 904 909.
Ruel, M.T., Alderman, H., 2013. Nutrition-sensitive interventions and
programmes: how can they help to accelerate progress in improving
maternal and child nutrition? Lancet 382 (9891), 536 551.
Safi, J., Joyeux, L., Chalouhi, G.E., 2012. Periconceptional folate deficiency
and implications in neural tube defects. J Pregnancy 2012, 295083.
Sifakis, S., Pharmakides, G., 2000. Anemia in pregnancy. Ann N Y
Acad Sci 900, 125 136.
27
Smit, E., et al., 2012. The effect of vitamin D and frailty on mortality
among non-institutionalized US older adults. Eur J Clin Nutr 66 (9),
1024 1028.
Sommer, A., West, K.W.J., 1996. Vitamin A deficiency: Health, sur-
vival, and vision. Oxford University Press, New York.
Spottiswoode, N., et al., 2012. Implications of malaria on iron deficiency
control strategies. Adv Nutr 3 (4), 570 578.
Stevens, G.A., et al., 2013. Global, regional, and national trends in hae-
moglobin concentration and prevalence of total and severe anaemia
in children and pregnant and non-pregnant women for 1995-2011: a
systematic analysis of population-representative data. LancetGlob
Health 1 (1), e16 e25.
Stoltzfus, R.J., 2011. Iron interventions for women and children in low-
income countries. J Nutr 141 (4), S756 S762.
Talukder, A., et al., 2000. Increasing the production and consumption of
vitamin A-rich fruits and vegetables: lessons learned in taking the
Bangladesh homestead gardening programme to a national scale.
Food Nutr Bull 21, 165 172.
Tanumihardjo, S.A., 2011. Vitamin A: biomarkers of nutrition for devel-
opment. Am J Clin Nutr 94 (2), S658 S665.
Thandrayen, K., Pettifor, J.M., 2012. Maternal vitamin D status: implica-
tions for the development of infantile nutritional rickets. Rheum Dis
Clin North Am 38 (1), 61 79.
The World Bank, 1994. In: McGuire, J., Galloway, R. (Eds.), Enriching
lives: overcoming vitamin and mineral malnutrition in developing
countries. Development in Practice Series. World Bank, Washington
DC.
The World Bank. World Development Indicators: Nutrition intake and sup-
plements. 2015 [cited11 August 2015; Available from: file:///C:/Users/
Marieke/Downloads/2.19_Nutrition_intake_and_supplements.pdf.
Thurnham, D.I., 2013. Nutrition of adolescent girls in low- and middle-
income countries. Sight and Life 27, 26 37.
Torheim, L.E., et al., 2010. Women in resource-poor settings are at risk
of inadequate intakes of multiple micronutrients. J Nutr 140 (11),
S2051 S2058.
UN (FAO/WHO), 2016. Resolution adopted by the UN General
Assembly on the UN Decade of Action on Nutrition. World Health
Organization, Geneva, A/RES/70/259. 2016. www.who.int (accessed
May 18, 2017).
UNICEF, 1990. The World Summit for Children. United
NationsChildren’s Fund, New York.
UNICEF. Global database: Household consumption of adequately
iodized salt. 2015 [cited; Available from: http://data.unicef.org/nutri-
tion/iodine.
WHO, 2009. Global prevalence of vitamin A deficiency in populations
at risk 1995-2005. WHO Global Database on Vitamin A Deficiency.
World Health Organization, Geneva, Switzerland.
WHO, 2010. Health systems financing: the path to universal coverage.
World Health Organization, Geneva.
WHO, 2012. Guideline: Daily iron and folic acid supplementation
in pregnant women. World Health Organization, Geneva,
Switzerland.
WHO, 2012. Resolution WHA65.6. Comprehensive implementation plan
on maternal, infant and young child nutrition. Sixty-fifth World
Health Assembly Geneva, 21-26 May 2012. Resolutions and deci-
sions, annexes. World Health Organization, Geneva [cited 2015 11
August 2015]; Available from: http://www.who.int/nutrition/topics/
WHA65.6_resolution_en.pdf?ua 5 1.
28 SECTION | I Need and Approach
WHO. e-Library of Evidence for Nutrition Actions (eLENA). Available
from: http://www.who.int/elena/en/. Last accessed: May 2015. 2015
[cited 2015 May 2015]; Available from: http://www.who.int/elena/
en/.
WHO, 2015. The global prevalence of anaemia in 2011. World Health
Organization, Geneva.
WHO, 2017. www.who.int (accessed May 11 Vitamin and Mineral
Nutrition Information System (VMNIS). World Health Organization,
Geneva.
WHO and FAO, 2004. 2nd ed Vitamin and mineral requirements in
human nutrition. 2nd edition, xix. World Health Organization, Food
and Agricultural Organization of the United Nations, Geneva,
p. 341.
WHO/FAO, 2006. In: Allen, L.H., et al., (Eds.), Guidelines on Food
Fortification with Micronutrients. World Health Organization/Food
and Agriculture Organization of the United Nations, Geneva.
WHO/SEARO, Dissemination of WHO guidelines and recommendations
on micronutrients: policy, practice and service delivery issues. 2015.
Wahl, D.A., et al., 2012. A global representation of vitamin D status in
healthy populations. Arch Osteoporos 7, 155 172.
Wessells, K.R., Singh, G.M., Brown, K.H., 2012. Estimating the global
prevalence of inadequate zinc intake from national food balance
sheets: effects of methodological assumptions. PLoS One 7 (11),
e50565.
Wieser, S., et al., 2013. Burden of micronutrient deficiencies by socio-
economic strata in children aged 6 months to 5 years in the
Philippines. BMC Public Health 13, 1167.
Yadav, U., et al., 2015. Polymorphisms in folate metabolism genes as
maternal risk factor for neural tube defects: an updated meta-
analysis. Metab Brain Dis 30 (1), 7 24.
Zimmermann, M.B., Boelaert, K., 2015. Iodine deficiency and thyroid
disorders. Lancet Diabetes Endocrinol 3 (4), 286 295.
Zimmermann, M.B., Hurrell, R.F., 2007. Nutritional iron deficiency.
Lancet 370 (9586), 511 520.
FURTHER READING
UNICEF, 2008. Sustainable elimination of iodine deficiency. Progress
since the 1990. World Summit for Children. United
NationsChildren’s Fund, New York.
Chapter 3
Developing National Strategies to Prevent
and Control Micronutrient Deficiency:
The Role of Food Fortification
Mduduzi N.N. Mbuya and Lynnette M. Neufeld
Global Alliance for Improved Nutrition (GAIN), Geneva, Switzerland
Chapter Outline
3.1 Introduction: Towards Country Led Strategies for Prevention
and Control of Micronutrient Deficiencies
3.2 Food Fortification and Nutrient Intakes: The Evidence
3.2.1 Large-Scale Food Fortification and Health Outcomes
3.2.2 LSFF and Nutrient Intakes
3.2.3 Targeted Fortification, Nutrient Intakes, and Health
Outcomes
3.2.4 Food Fortification and Risk of Adverse Effects
3.3 Implications for National Fortification Plans
3.4 Food Fortification and Other Approaches to Control of
Micronutrient Deficiencies
3.1 INTRODUCTION: TOWARDS
COUNTRY LED STRATEGIES FOR
PREVENTION AND CONTROL OF
MICRONUTRIENT DEFICIENCIES
Undernutrition in all its forms is responsible for an esti-
mated 3.5 million preventable maternal and child deaths
annually and has enormous human and economic costs in
the long run (Alderman et al., 2016; Bhutta et al., 2013).
In 2008, the Lancet issued a five-part series on nutrition,
which provided and discussed systematic evidence for the
impact of a set of interventions focused on the window of
opportunity from pregnancy to 2 years of age. A central
message of the series was that although effective nutrition
actions exist, they have not been implemented at scale,
nor has program performance and impact been adequately
assessed. One of the papers in the series (Bryce et al.,
2008) presented seven key challenges that militate against
the effective implementation and coordination of the
actions at national level: getting nutrition on the list of
priorities, and keeping it there; doing the right things; not
Food Fortification in a Globalized World. DOI: https://doi.org/10.1016/B978-0-12-802861-2.00003-1
Copyright © 2018 Elsevier Inc. All rights reserved.
3.5 Evidence and Decision Making: A Need for Data-Driven
29 Coordination 34
30 3.6 Nutrition Actions to Enable and Support Food
31 Fortification 35
31 3.6.1 Nutrition Actions: Everybody’s Business, and Nobody’s
Responsibility 35
31 3.6.2 Nutrition Actions: Calling All Hands on Deck 36
32 3.6.3 Nutrition Actions: Asking the Right Questions 37
32 3.7 Conclusion 38
References 38
33
doing the wrong things; acting at scale; reaching those in
need; data-based decision-making; and building strategic
and operational capacity.
The authors consequently issued two charges, one to
country level nutrition leaders calling for them to review
their existing strategies and programs to ensure that prior-
ity is given to interventions with a proven effect on under-
nutrition among pregnant women and children younger
than 2 years of age, and then to develop feasible strategies
for increasing public demand for these interventions and
delivering them at scale. The second charge was to nutri-
tion leaders at the international level to support countries
in assessing their readiness to act at scale, to identify
gaps, and to build sufficient capacity at the national level
to develop and maintain functional nutrition systems that
can assume responsibility for accelerating progress. This
call was subsequently operationalized in the development
of the Scaling Up Nutrition (SUN) initiative. While prog-
ress has been realized in mobilizing political commitment
and developing multisectoral stakeholder mechanisms
within the SUN framework, challenges pertaining to the
29
30 SECTION | I Need and Approach
use of these mechanisms to align actions and resources
still remain (International Food Policy Research Institute,
2016). In other words, the majority of the seven key chal-
lenges persist.
In this chapter, we present and discuss issues pertain-
ing to the development of national strategies to prevent
and control micronutrient deficiency, with specific focus
on the role of food fortification in the context of these fra-
meworks. As context, we present a brief overview of the
evidence of impact, then discuss fortification in the con-
text of other micronutrient deficiency control interven-
tions and reflect on the constraints and opportunities
towards the processes of building commitment, develop-
ing and monitoring micronutrient deficiency control pro-
grams, and moving toward acting at scale to implement
effective country-owned fortification programs.
3.2 FOOD FORTIFICATION AND
NUTRIENT INTAKES: THE EVIDENCE
Food fortification programs have the express objective of
enhancing the nutritional quality of foods in order to con-
tribute towards addressing demonstrated nutrient deficien-
cies (Dwyer et al., 2014) in the contexts of a combination
of marginal diets, vulnerable population segments (as
defined by either geography or life stage), and other dri-
vers of deficiency. Consequently, the goal of any fortifi-
cation program is to shift averages and distributions of
intakes of nutrients towards those considered adequate, as
illustrated in Fig. 3.1. This can be achieved through dif-
ferent approaches differentiated by target group. These
distinct, but largely overlapping, approaches can be
Current distribution
of intakes
Distribution of
“adequate intakes”
Intake of essential micronutrient
FIGURE 3.1 Comparing current and ideal distributions in the popula-
tion intakes of an essential micronutrient.
broadly categorized into (1) population-based/large-scale
fortification and (2) targeted fortification.
1. Large-scale food fortification (LSFF) entails fortifying
foods that are widely consumed by the general popu-
lation, such as cereal grains (e.g., wheat and maize
flour, rice, among others), condiments, and milk. The
basic assumption underlying this approach is that the
intake of one or more micronutrient(s) is suboptimal
at the population level leading to a large proportion of
the population being at risk of either being or becom-
ing deficient in essential micronutrients. Respectively,
the control of iodine deficiency disorders through salt
iodization (Zimmermann and Andersson, 2012) and
mandatory addition of folic acid to wheat flour to
reduce the risk of birth defects (Youngblood et al.,
2013) represent these scenarios and are practices that
have been successfully introduced in many countries
globally. LSFF therefore has the implicit goal of shift-
ing average nutrient intake at a population level
towards the recommended level. It is often mandated
and regulated by the government (mandatory), but can
also be market-driven (voluntary) when food manufac-
turers undertake, within government-set regulatory
limits, a business-oriented initiative related to increas-
ing their market share through added value of the
product—in this case by adding essential micronutri-
ents to processed foods.
2. Targeted fortification entails fortifying foods that are
designed for specific population subgroups at higher
risk of either being or becoming deficient in essential
micronutrients due to age, life stage, or other reasons.
Examples of this approach include complementary
foods for young children, foods developed for school
feeding programs, special biscuits for children and
pregnant women, and rations (fortified blended foods)
for emergency feeding and displaced persons.
Household fortification, through soluble or crushable
tablets, micronutrient-based powders (sprinkles),
micronutrient-rich spreads also fall under this category
and are particularly helpful for improving local foods
fed to infants and young children, or filling the gap in
contexts where the reach of universal fortification is
ineffective because staple foods are processed at the
household or local level. The assumption underlying
targeted fortification is similar to that of large-scale
fortification, except that in this case a particular seg-
ment of the population is at risk, either due to biologi-
cal factors (high nutrient demands due to the
pregnancy and lactation states, the rapid growth and
development that characterize infancy and early child-
hood), or due to localized chronically or acutely mar-
ginal diets resulting in deficiency risk.
Another random document with
no related content on Scribd:
back
back
back
back
back
back
back
back
back
back
back
back
back
back
back
back
back
back
back
back