Food Fortification in a Globalized World

M G Venkatesh Mannar
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Food Fortification in a Globalized World
This page intentionally left blank
Food Fortification
in a Globalized World

Edited by

M.G. Venkatesh Mannar

Richard F. Hurrell
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Contents

List of Contributors xv 2.3 Conclusions 24

Foreword xvii References 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 Lynnette M. Neufeld
Current Status, and Potential for
Globalization 3.1 Introduction: Towards Country Led
Strategies for Prevention and Control
M.G. Venkatesh Mannar and Richard F. Hurrell of Micronutrient Deficiencies 29
3.2 Food Fortification and Nutrient Intakes:
1.1 Background 3 The Evidence 30
1.2 Early Successes With Food Fortification 5
3.2.1 Large-Scale Food Fortification and
1.3 Types of Fortification 6
Health Outcomes 31
1.4 Selection of Vehicles 7
1.5 Biofortification 8 3.2.2 LSFF and Nutrient Intakes 31
1.6 Current Situation, Issues and Challenges 9 3.2.3 Targeted Fortification, Nutrient
1.7 Concluding Thoughts 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
Ian Darnton-Hill 3.5 Evidence and Decision Making:
A Need for Data-Driven Coordination 34
2.1 Introduction 13 3.6 Nutrition Actions to Enable and
2.2 The Gap in Micronutrient Intakes at Support Food Fortification 35
Population Level and the Resultant 3.6.1 Nutrition Actions: Everybody’s
Deficiency Outcomes Being Addressed 13 Business, and Nobody’s
2.2.1 Iron Deficiency and Anemia 15 Responsibility 35
2.2.2 Iodine 17 3.6.2 Nutrition Actions: Calling All Hands
2.2.3 Folate and Neural Tube Defects on Deck 36
(NTDs) 18 3.6.3 Nutrition Actions: Asking the Right
2.2.4 Vitamin A Deficiency 19 Questions 37
2.2.5 Zinc 21 3.7 Conclusion 38
2.2.6 Other Micronutrients 22 References 38

v
vi Contents

Section II 5.7 The Way Forward for National

Mandated Fortification Programs 60
Recommendations and Guidance 41 Acknowledgments 61
References 61
4. Using Dietary Reference Values to Further Reading 62
Define Fortification Levels for
National Programs 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 6.2.1 Documented Evidence of MND 63
4.2.1 Average Requirements and Upper 6.2.2 Nutritional Relevance of
Levels 43 Market-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
4.4 Nutrient Data Bases 45 6.2.6 Communication—Nutrition and
4.5 Correcting for Day-to-day Variance in Health Claims and Regulations 65
Intake 45 6.2.7 Organoleptic Impact and Stability 65
4.6 Bioavailability Factors 45 6.2.8 Bioavailability Versus Organoleptic
4.7 Exceeding Upper Levels of Intake 46 Quality: Example of Iron 66
4.8 Using Software 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 Biofortification 66
Section III 6.3.3 Public Private 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
5.1 Introduction: The Rationale for
Deficiencies
National Food Fortification Programs 53 Howarth E. Bouis
5.2 A Snapshot of National Food Fortification
Programs Around the World 53 7.1 Agriculture and Mineral and Vitamin
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-Effectiveness 70
5.3.2 Voluntary Fortification 56 7.3 Nutritional Bioavailability and Efficacy
5.3.3 Fortified Foods as a Component Evidence 71
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
5.6.1 The Build/Expand Stage 58 7.4.1 Transgenic Approaches 73
5.6.2 The Improve Stage 59 7.4.2 International Nurseries/Global Testing 73
5.6.3 The Measure/Sustain Stage 60 7.4.3 Low-Cost, High Throughput Methods 74
 Contents vii

7.4.4 Releases of Biofortified Crops 74 9.2.2 Stages of Financing of National

7.5 Delivery Experiences in Target Counties 74 Food Fortification Programs 94
7.5.1 Vegetatively Propagated Crops 75 9.2.3 Level of Financing Required 95
7.5.2 Cassava in Nigeria and DR Congo 75 9.2.4 Sources of Financing 95
7.5.3 Self-Pollinated 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 Fortification 96
7.5.6 Hybrid Crops 76 9.3.1 Ecology 96
7.5.7 Maize in Zambia 77 9.3.2 Economic 97
7.5.8 Pearl Millet in India 77 9.3.3 Political 97
7.5.9 Lessons Learned From Delivery 77 9.3.4 Cultural 98
7.6 Building Blocks for Global Delivery 77 9.4 Conclusion 98
7.6.1 Standards and Regulatory 78 References 99
7.6.2 Multilateral Institutions 78
7.6.3 Private Sector 78
7.6.4 NGOs 78 10. Creating Consumer Demand and
7.6.5 Moving Beyond Target Countries to Driving Appropriate Utilization of
Partnership Country Strategies 79 Fortified Foods
7.7 A Future Vision To Drive and Guide
Mainstreaming 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 an
Efficacy, and Effectiveness of Biofortified
Important Role in Driving Demand 102
Foods 81
10.2.1 Affordability and Value-for-
Money 102
Section IV 10.2.2 Availability as a Driver of
Demand 104
Technical and Business 10.2.3 Perceived Quality and Product
Considerations 83 Attributes 106
10.2.4 Packaging as Means to
8. Grain Fortification Processes, Communicate 106
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 J. Montgomery 10.3.2 From First Trial 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 References 110
8.1.1 Introduction 85 Further Reading 112
8.2 Processes 86
8.3 Technologies 87
8.4 Implementation Criteria 87
8.5 Conclusion 90 11. The Importance of Public Private
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 Fortification 11.2 Why Collaboration Between the
Luc Laviolette Private and Public Sector is Critical
for Success 114
9.1 Introduction 93 11.3 Frameworks, Tools, and Processes for
9.2 Financing of Food Fortification 93 Effective Public Private Collaboration 114
9.2.1 Food Fortification is a Good 11.4 Examples of Public Private
Investment 93 Collaboration 115
viii Contents

11.4.1 National Fortification Alliances 115 13.5.2 Delivery Options for Fortified
11.5 Gaps and Opportunities for Improved Rice 138
Public Private Collaboration 118 13.6 Conclusion 140
11.5.1 Human Capacity 118 References 140
11.5.2 Setting Legislation and Standards
for Impact 118
11.6 Regulatory Monitoring 118
14. Salt
11.7 Conclusion 118 M.G. Venkatesh Mannar
References 119
Further Reading 119 14.1 Salt as a Carrier of Nutrients 143
14.2 Iodization of Salt 143
14.2.1 Consolidation and
Section V Modernization of the Salt
Industry 144
Fortification Vehicles 121 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
Helena Pachón Universal Salt Iodization 145
14.3.1 Making Salt Iodization a Global
12.1 Introduction 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 Guidelines for Fortification 124 14.3.3 Supporting Small Salt Producers 147
12.4 Countries With Mandatory and
14.3.4 Engaging the Processed Food
Voluntary Legislation 124
12.5 Nutrients, Fortificants, and Levels Industry 148
Included in Legislation/Standards 124 14.3.5 Monitoring and Adjusting Iodine
12.6 Coverage and Compliance in Intakes 148
Mandatory and Voluntary 14.3.6 Double Fortified Salt 148
Countries 126 14.4 Multiple Fortification of Salt 149
12.7 Health Impact From Flour 14.5 Scale Up of DFS 150
Fortification 127 14.6 Cost of Multiple Fortification 150
12.8 Way Forward to Accelerate the 14.7 Conclusions 150
Coverage and Impact of Flour References 151
Fortification 127 Further Reading 151
Acknowledgements 128
References 128
15. Condiments and Sauces
Visith 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 Scott Montgomery
15.3 Fortification Process 154
13.1 Introduction to Rice Fortification 131 15.3.1 Solid Condiments 154
13.2 History of Rice Fortification 132 15.3.2 Semi-Solid Condiments 155
13.3 Choice of Technologies 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
Technologies From a Consumer References 156
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
and Where? 138 16.1 Bouillon Cubes 159
16.2 Estimated Use and Consumption
13.5.1 Rice Landscape Analysis 138
of Bouillon Cubes 159
 Contents ix

16.3 Current Fortification Practices 160 19. Breakfast Cereals

16.3.1 Iodine 160
16.3.2 Iron 161 Kathryn Wiemer
16.3.3 Future Research Directions 163 19.1 Introduction 183
16.3.4 Other Fortificants Added to 19.1.1 Policy and Regulatory History 183
Bouillon Cubes 164 19.2 Cereal Fortification Considerations 184
16.4 Conclusions and Outlook 164 19.2.1 Scientific 184
References 164 19.2.2 Technical and Processing
Method 186
17. Micronutrient Fortification of Edible 19.3 Impact of Cereal Fortification on
Nutrient Intakes 189
Oils 19.4 Future Considerations 189
Levente László Diosady 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 168
17.4 Technology for Edible Oil Fortification 170
17.5 Postprocessing Requirements in Oil 20. Efficacy and Safety of Iron
Fortification 170 Fortification
17.5.1 Quality Control 171 Richard F. Hurrell
17.5.2 Stability of Vitamins 171
17.5.3 Safety and Toxicity 20.1 Iron Fortification Compounds With
Considerations 172 Confirmed Efficacy 196
17.6 Standards and Regulations 172 20.1.1 Defining the Iron Fortification
17.6.1 Quality Standards 172 Level 196
17.6.2 Monitoring and Enforcement 172 20.1.2 Ascorbic Acid 197
17.6.3 Commercially Available 20.1.3 Ferrous Sulfate 197
Premix for Oil Fortification 172 20.1.4 Ferrous Gluconate 198
17.7 Biological Efficacy of Fortified Oil 173 20.1.5 Ferrous Fumarate 198
17.8 Current Status of Micronutrient 20.1.6 Ferric Pyrophosphate 198
Fortification of Edible Oils 173 20.1.7 Electrolytic Iron 199
17.9 Conclusion 173 20.1.8 Sodium Iron
References 174 Ethylenediaminetetraacetic Acid 200
Further Reading 174 20.1.9 Ferrous Bisglycinate 201
20.2 Technologically Modified Iron
18. Milk and Dairy Products Compounds With Confirmed Efficacy 201
20.2.1 Encapsulated Ferrous Sulfate 201
Daniel López de Romaña, 20.2.2 Encapsulated Ferrous Fumarate 202
Manuel Olivares and Fernando Pizarro 20.2.3 Micronized Dispersible Ferric
18.1 Introduction 175 Pyrophosphate SunActive Fe 202
18.2 History 175 20.3 Other Potentially Useful Compounds 202
18.3 Current Practices, Micronutrients 20.3.1 Ferric Ammonium Citrate 202
Added, and Compounds Used 176 20.3.2 Ferrous Lactate 203
18.4 Vehicle Consumption Patterns 177 20.3.3 Ferric Orthophosphate 203
18.5 Technologies 177 20.3.4 Ferrous Succinate 203
18.6 Potential for Impact 179 20.4 Current Developments in Iron
18.7 Challenges 180 Fortification 203
References 180 20.4.1 Phytase 203
x Contents

20.4.2 Nano Iron 203 22.3 Nutritional Goitrogens That Influence

20.4.3 Aspiron 203 Iodine Efficacy 224
20.5 Suggested Iron Compounds for 22.4 Assessment of Iodine Status in
Different Food Vehicles 203 Populations 225
20.5.1 Cereal Flours, Bread and Pasta 203 22.5 The Safety of Iodized Salt Programs
20.5.2 Rice 204 and the Effects of Iodine Excess 225
20.5.3 Salt 204 22.6 Conclusions 228
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 Milk Products 205 23. Global Status of Folic Acid
20.5.7 Beverages 205 Fortification—Progress and Gaps
20.5.8 Cereal-Based Complementary
Foods 205 Greg S. Garrett and Lynn B. Bailey
20.5.9 Micronutrient Powders 205 23.1 Introduction 231
20.5.10 Chocolate Drink Powders 205 23.2 Global Status of Folic Acid
20.5.11 Breakfast Cereals 205 Fortification—Progress and Gaps 232
20.6 Potential Health Risks of Iron 23.3 Research Gaps: Other Potential
Fortification 205 Fortifiable Vehicles and Innovations 235
20.6.1 Infectious Disease 205 23.4 Summary and Conclusion 237
20.6.2 Iron Overload 206 Acknowledgments 237
20.6.3 Cardiovascular Disease 206 Competing Interests 237
20.6.4 Diabetes Type 2 207 References 237
Further Reading 239
20.6.5 Cancer 207
20.7 Balance Between Benefit and Risk 207
References 207
24. Assessing all the Evidence for
Risks and Benefits With Folic Acid
21. Zinc Fortification Fortification 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 Acid Fortification of Grain
21.2 Zinc Bioavailability and Metabolism 213 Products 241
21.3 Measuring Zinc Status and Deficiency 215 24.2 Investigation of Effects of High
21.4 Health Risks and Benefits of Zinc 215 Folic Acid Intakes 241
21.5 Zinc Fortificants 216 24.3 Vitamin B12 Folic Acid Intervention 242
21.6 Native Zinc and Zinc-Fortified Foods 216 24.4 Unmetabolized Folic Acid and Folic
21.7 Safety and Efficacy of Fortification 217 Acid Excess 243
21.8 Conclusions 218 24.5 Evidence of Increased Vulnerability
References 218 to Folic Acid Excess in Populations
With Genetic Polymorphisms 244
24.6 Concluding Remarks 245
22. Efficacy and Safety of Iodine References 245
Fortification
Michael B. Zimmermann
25. Nutrient-Wise Review of Evidence
22.1 Introduction: The Iodine Deficiency and Safety of Fortification: Vitamin A
Disorders 221
22.1.1 Diffuse Goiter and Mutinodular Sherry A. Tanumihardjo
Toxic Goiter 221
25.1 Chemical Forms of Fortificants 247
22.1.2 Neurocognitive Impairment 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 That Are Being Fortified 249 Fortification 269
25.7 Biofortification of Staple Foods With 27.2.7 Nutritional Benefits of Calcium
Provitamin A Carotenoids 249 Fortification 269
25.8 Concerns and Limitations 250 27.2.8 Safety of Calcium 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
Fortificant 250
25.8.3 The Potential for Excessive Section VII
Intakes 250
References 251
Program Performance
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 Deficiency 255
26.2 Why Vitamin B12 Status Is Important 255 Laird J. Ruth, Svenja Jungjohann,
26.3 Cofortification of Vitamin B12 and Folic Helena Pachón and Mary Serdula
Acid 256
28.1 Introduction 275
26.4 Diagnosis of Deficiency and Depletion 257
28.2 Overview of Principal Components
26.5 Requirements, Bioavailability, and
of An M&E System for Food
Safety 257
Fortification 276
26.6 Expert Consensus on Recommended
Vitamin B12 Fortification 258 28.2.1 Regulatory Monitoring 276
26.7 Experience With Vitamin B12 28.2.2 Household/Individual
Fortification 258 Monitoring and Evaluation 277
26.8 Conclusions 259 28.3 Overall Monitoring and Evaluation
References 260 Framework 278
28.3.1 Step 1: Engage Stakeholders 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 D 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 and Share Lessons 281
27.1.4 Current Populations Intakes of 28.4 Conclusion 281
Vitamin D and the Case for Acknowledgments 281
Food Fortification 264 References 281
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 Vitamin D 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 Introduction 283
27.2.3 Deficiency 268 29.2 Background to Regulatory Monitoring
27.2.4 Food Sources of Calcium 268 of Fortified Foods 284
27.2.5 Calcium Fortificants 268
xii Contents

29.3 Common Challenges in 30.5 Fortified Food Intake 294

Implementing Effective Regulatory 30.6 Micronutrient Intake From Fortified
Monitoring 285 Food 294
29.4 Identified Good Practices Which 30.7 Way Forward to Accelerate
Can Help Countries Overcome Consumption Monitoring of Fortified
Barriers 285 Food 295
29.4.1 Simplify the Process of Acknowledgments 296
Compliance Data Collection Disclaimer 296
and Management 286 References 296
29.4.2 Include Fortification in Existing
Food Safety Mandates and 31. Economics of Food Fortification
Inspection Forms 287
29.4.3 Identify and Implement Effective Susan Horton and M.G. Venkatesh Mannar
Incentive and Penalty Schemes 31.1 Economic Costs of Fortification 299
for Industry 287 31.2 Cost-Effectiveness and Cost Benefit 301
29.4.4 Increase the Role of Civil 31.3 Conclusions 303
Society and Consumer Groups 287 References 303
29.4.5 Establish Clear Roles,
Responsibilities, and Working
Environments for Government
32. Impact Evaluation of Food
Inspectors 287 Fortification Programs: Review
29.4.6 Ensure a Trained Cadre of of Methodological Approaches
Inspectors 288 Used and Opportunities to
29.4.7 Elevate the Public Profile of Strengthen Them
Fortification to Motivate
Lynnette M. Neufeld and Valerie M. Friesen
Government to Improve
Compliance 288 32.1 Introduction 305
29.5 Policy Recommendations and 32.2 Brief Overview of Findings From
Implications 289 Fortification Program Impact
References 289 Evaluations 306
Further Reading 290 32.3 Evaluation Designs Used to
Assess Impact of Food Fortification
Programs 309
30. Consumption Monitoring: 32.4 Beyond Impact: Assessing Program
Coverage, Provision, Pathways and Evaluability 312
32.5 Implications for Improving Food
and Utilization Fortification Program Evaluations 312
Helena Pachón and Omar Dary 32.6 Conclusions 313
References 314
30.1 Introduction 291
30.2 General Considerations 291
30.2.1 Terminology 291
30.2.2 Assumptions 292 Section VIII
30.2.3 When to Initiate Consumption National Program Case Studies
Monitoring 292
30.2.4 Relationship With Impact
and Lessons Learned
Evaluations 292
30.2.5 Periodicity of Consumption 33. National Program Case Studies and
Monitoring/Food Consumption Lessons Learned: South Africa
Patterns 292
Philip Randall
30.2.6 Maximizing Resources 292
30.3 Fortified Food Coverage 293 33.1 National Fortification Alliance 320
30.4 Micronutrient Provision 33.1.1 Impact Evaluation 323
(or Additional Micronutrient 33.2 Lessons Learnt 324
Content per Unit Weight) From References 324
Fortified Food 293 Further Reading 324
 Contents xiii

34. Food Fortification in Senegal: 37. National Program Case Studies and
A Case Study and Lessons Learned Lessons Learned From Bangladesh
Ka Abdoulaye and Caroline Manus Basanta Kumar Kar
34.1 Introduction 327 37.1 Introduction 349
34.2 Food Fortification Program (FFP) in 37.2 Building a Shared Vision on the Need
Senegal 327 and Benefits of Vitamin A Fortification 349
34.2.1 Cellule de Lutte contre la 37.3 Phase 1: Strategizing Mandatory
Malnutrition (CLM): An Enabling Fortification 350
Environment for Food 37.4 Phase 2: Advocacy and Enactment
Fortification in Senegal 327 of the Law 350
37.5 Phase 3: Managing and Mitigating
34.2.2 Achievements of the FFP 328
Post Enactment Challenges 351
34.3 Program Challenges 329
37.6 Phase 4: Enforcement of the Law and
34.4 Lessons Learned 329
Implementation of the Program 351
34.5 Conclusion 331
37.7 Key Drivers of Success 352
References 331
37.8 Lessons Learned 352
Further Reading 352
35. Equity of Impact on Anemia and
Iron Status of the Food Fortification
Program of Costa Rica
Section IX
Business Case Studies
Reynaldo Martorell
35.1 Introduction 333 38. Business Considerations for
35.2 Program Description 334 Food Fortification: Cargill
35.3 Results 334
35.4 Discussion 336 India Experience With
35.4.1 Attribution of Causality 336 Oil Fortification
35.4.2 Missed Opportunities in Siraj A. Chaudhry
Evaluation 338
35.4.3 Explaining the Equity of the 38.1 Introduction 357
Impact on Anemia 338 38.2 Fortification: A Step in the Right
Direction 358
35.4.4 Lessons From Costa Rica for
38.3 Oil Fortification—A Viable Means to
Effectiveness Evaluations 339
Address Vitamin A and D Deficiencies 358
References 339
38.4 India Oil Consumption Facts 358
Further Reading 340
38.5 Lessons From Business: Cargill
India Private Limited: Experience
36. Food Fortification in Canada With Fortifying Edible Oil 359
38.6 The Vision 359
Anthea Christoforou, Sheida Norsen 38.7 Technology 360
and Mary L’Abbé 38.8 From Concept to Implementation 360
38.9 Financial Implications 361
36.1 Mandatory Food Fortification in
38.10 Branding and Marketing 361
Canada 341
38.11 Reaching the Bottom of the Pyramid 361
36.1.1 The Case of Vitamin D: 38.12 Building on the Momentum 361
A Public Health Success Story? 342 References 362
36.2 Discretionary Fortification in Canada 343 Further Reading 362
36.2.1 Policy Evolution 343
36.2.2 Prevalence of Discretionary
Fortification in Canada 344 39. Micronutrient Fortification
36.2.3 Nutrition and Health Implication of Bouillon Cubes in Central and
of Discretionary Fortification in West Africa
Canada 344
Petra Klassen-Wigger, Maarten Geraets,
36.3 Conclusions 346
Marie C. Messier, Patrick Detzel,
References 346
Henri P. Lenoble and Denis V. Barclay
xiv Contents

39.1 Introduction 363 Section X

39.2 Implementation of Iron Fortification
of Bouillon 364 Future Trends and Strategies
39.3 Nutritional Relevancy 364
39.4 Bioavailability 365 40. Future Trends and Strategies in
39.5 Stability/Shelf Life Test 367
Food Fortification
39.6 Safety 367
39.7 Technical Requirement and M.G. Venkatesh Mannar, Greg S.
Challenges 368 Garrett and Richard F. Hurrell
39.7.1 Selection of the Iron
40.1 The Way Forward 379
Fortification Compound 368
40.2 Conclusion 381
39.7.2 Homogeneity 369
References 381
39.7.3 Quality Assurance 369 Further Reading 381
39.8 Communication of Nutritional
Benefits to Consumers 369
39.8.1 Understanding Lower-Income Index 383
Consumers 369
39.9 Business Impact 370
39.10 Future Challenges 370
39.10.1 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
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Section I

Need and Approach

This page intentionally left blank
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.
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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.
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Another random document with
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a village a much better general effect is thus gained. On the other
hand a good effect may be gained by giving a block of houses one
tone throughout, matching the colour of the roof. The result is quiet
and unobtrusive, and one which is very desirable in the cottage, where
the features are necessarily brought close together. The tarred plinth,
however, should always be used with rough-cast.
Half-timber should be used sparingly. While the bye-laws insist on a
9-in. wall being at the back, an unwarranted present and future
expense is incurred by its use; and an effect equally as good,
moreover, may be obtained with rough-cast, weather boarding, or
whitewash. Half-timber one lives to regret, for the weather tells sadly
upon it, and it demands constant repair.
A small cottage with an equal distribution of equal-sized windows is
far from desirable. In a pair of cottages where there are four equal
rooms facing the road, four equal windows would at first sight seem
unavoidable, although such an arrangement would be fatal to the
elevation. It is better to put a secondary light to the rooms at the
extremities, getting additional light from the side, and thus by contrast
giving greater importance to the larger windows in the centre, or even
to omit the smaller windows, if adequate light can be obtained without
them. The blank space might then be used for the training up of
climbing plants. A certain number of windows is indispensable in a
cottage, but, without stinting light, the aim should rather be to repress
any superfluity. By the means suggested the view from the interior is
sometimes agreeably varied.
Other features are dealt with in the descriptions of the various
cottages to which they have particular reference.
 THE LAYING OUT OF A MODEL
VILLAGE.
Let it be supposed that land has been bought to be laid out as a
model village. Whether this has been done by a company, a
municipal body, or by an individual, is not material to the present
purpose. Assuming that the selection of the site has had careful
consideration, and that it is suitable for the development of a village,
what is the first step? Before turning a sod the clearest conception of
the finished scheme must have been formed. A dozen cottages or so
erected before considering the future of the whole project may
involve endless trouble at a later stage. The initial proceeding,
therefore, is to make the general plan as complete and final as
possible before commencing actual operations. Up to the present it
has been the difficulty of co-operation among landlords, perhaps
unavoidable, either by the piecemeal acquisition of land or the fitful
demand for building, which has been the cause of many of our towns
and suburbs being the reverse of pleasing. A century or so ago,
when domestic architecture was a traditionally living art, and building
was conducted less hurriedly, a certain charm of effect was no doubt
obtained by this accidental or fitful extension, though convenience
was certainly not always considered; but in the present day we
should avail ourselves of the opportunity which a large or co-
operative scheme offers for a convenient and agreeable disposition
of buildings.
Regard of Physical Features.—As the following suggestions
do not refer to any specific example of land which is to be laid out as
a model village, they can only be regarded as having general
applicability. The treatment of particular land depends upon its
peculiar physical features. Land in a gently undulating district, for
instance, must be dealt with in quite a different manner from that in
flat country. The natural features themselves must be the basis of
any satisfactory treatment, and they are to be made the most of, not
only with regard to their intrinsic beauty, but also any material
advantages they may offer.
Advisory Architect.—If a village is being developed by an
individual in a private capacity it is not improbable, indeed it is very
natural, that he will expect the general operations to be carried out in
accordance with his particular taste or fancy, which, however, may
happen to be far from practical or artistic, and his scheme is likely to
suffer accordingly. So too in the case of an estate developed by a
governing body consisting of men who are not qualified for the task,
the possibility of failure is equally great. The best course is to employ
an advisory architect about whose qualifications there is no doubt,
who should work in conjunction with the surveyor from the outset. It
may be suggested, now that the movement is making considerable
progress, that the Royal Institute of British Architects should be
asked to suggest an architect in such cases. A greater variety,
however, in the plan and design of the houses might perhaps be
secured by employing more than one architect. A man’s ideas are
liable to run in a groove; and even if variation is introduced in detail
there is likely to be a similarity in general character. Moreover, where
two or more architects are engaged, a healthy rivalry might result in
the designing of houses which shall fulfil all the conditions of
convenience, compactness, and economy. The respective work of
the various architects might be confined to particular streets, but a
regular system of variation should be avoided. Method should not be
too obtrusive or the arrangement too mechanical. The advisory
architect must be selected with judgment, for on him will devolve the
working out of the general road-scheme, and this will demand more
talent than the merely practical man possesses.
The caution already urged against doing anything on the estate
without mature consideration expressly applies to the cutting of
roads and the reservation of spaces. Given a map of our land, the
fancy is not usually slow in disposing of it; and it is only with the
progress of operations, when a number of unforeseen demands
make themselves disagreeably formidable, that it is seen how
wanton this ready fancy has been.
The Selection of Centres.—The first questions to be decided
are the number and positions of the centres, for it is to and from
these that the most convenient and accessible connections must be
planned, and the centres themselves should be reserved as the sites
of parks, principal buildings, shops and the like.
If the land is already entered by one or more turnpike roads which
may not be diverted, these should guide the cutting of the new
roads, and the chief centres of the village must be made as
accessible as possible from them. If an existing road only
approaches the land, and only one connection is deemed necessary,
the connection should be constructed to suit the village as a whole,
without partiality to any one extremity, always keeping the centres in
view. It is nearly always better to work to the contour of the land,
taking a gentle sweep in preference to a straight line.
The site of the chief centre, not forgetting to keep in view its
general accessibility, should if possible be on the highest point of the
village, such a position giving prominence over the whole, as well as
a more imposing elevation and dignity to the principal buildings
which are to be erected thereon. The nature of the buildings would
depend altogether on the size of the scheme. In the case of a garden
city they would possibly include council chambers, theatre, museum,
library or other monumental buildings of a like character, and as
large spaces as possible should be reserved around them for
extensions and gardens. A great city, in which it has been decided to
build a cathedral, has found itself before now in the dilemma of
having no suitable site available, and the monument of beauty has
had to make the best of beggarly and ugly neighbours. It is as well to
profit by the errors of the past, and the utmost should therefore be
done to save a garden city or model village from ever getting
congested at its chief centre.
 The other centres should be places of distinct interest, such as
schools, railway station, or market-place, but secondary to the chief
one.
Roads.—The buildings will not be sky-scrapers, and the roads,
therefore, will not, in order that they may be ventilated, have to be
set out in straight lines in order to be wind-swept, intersecting at
unpleasing right angles like a gridiron. Though the main streets
should be planned with some degree of straightness for the
convenience of getting to and from important places, there is no
reason why regularity should be sought after for its own sake; at the
same time an unnecessary irregularity should be as much avoided.
Where one straight road unavoidably meets another at right angles,
it is a good plan to widen the point of intersection. This particularly
applies to a road taking a hill straight—that is, at its shortest length.
A pleasing perspective will be given by thus widening, and on the
triangular space formed might be erected a fountain or monument,
with or without a grass plot. As an alternative, if the ground is too
valuable to be so disposed of, the road might be terminated by
slightly curving it to the left or right, and the corner remaining used
for building upon. In the residential portion of the village or garden
city, roads running due east and west should be avoided if possible.
When this precaution has been taken, much scheming to get the sun
on the front as well as the back of the house will be spared. As is
well known, a kitchen with a south aspect is unbearable in the heat
of the summer. Where the road unavoidably runs east and west, the
gardens of houses on the north side should occupy the front and not
the back of the plot.
Trees should be planted in all roads, and the chief roads should be
arranged on the boulevard plan, allowing the utmost freedom to the
pedestrian. A few spaces might be reserved for shelters, and the site
for a bandstand might be timely chosen. As much as possible should
be done to give breadth to all thoroughfares, and to this end the
building-line of the houses should be well back from the road—thirty
feet at least—the ample front-garden giving a refreshing greenness
to the prospect, besides a better perspective to the houses. The
width of roads should be from forty to fifty feet, with paths of from
eight to twelve feet, not less.
Minor open spaces, such as playgrounds for young children, are
pleasant along the road side, but road-making is costly, and
economy in all probability will have to be studied; back land,
therefore, should be utilised for them at the bottom of garden plots.
Street Elevations.—In building a road of houses the expense
would of course be considerable if to get variety a different plan and
different details were employed for each house. Other methods must
be adopted. In the case of twenty houses it would be well to get as
many details, such as windows, doors, and door-frames, the same
(or, at any rate, half of one kind and half of another), and monotony
should be avoided by variation in the disposition of these features.
An extensive elevation may also be made interesting by the
treatment of a porch here, the addition of a bay window there, and
the use of rough-cast somewhere else. An irregular building-line,
where possible, is to be preferred. In a block of three cottages a
pleasing effect is gained by projecting or recessing the middle one,
or putting it with its long axis parallel with the road, and so forming a
forecourt in front.
Service of Natural Advantages.—Whatever natural
advantages the land may possess, such as woods, pools, or streams
(where they are not included in a park), should border, or be seen
from, the road—that is if they merit the expense of road-making. Few
things are more picturesque than a stream at the roadside (as at
Tissington in Derbyshire), especially if spanned here and there by
small bridges (as at Bourton-on-the-Water), and by their presence
the road will be widened from house front to house front. The water
of a stream should never be utilised for a manufacturing purpose
where it afterwards flows through the village, except for generating
electric power or other clean uses. If there is an avenue of old trees
it should be secured for one of the roads.
Shopping.—The chief shopping will be best placed just without
and surrounding the main centre, and that of less importance round
the minor centres.
 Factories.—Supposing that the raison d’être of the village or
garden city be one or more industries in which many of the
inhabitants are employed, where, it will be asked, are the factories to
be placed? Without a definite example of land, it is difficult to give a
definite reply. Many things are essential to such sites—for instance,
the adjacency of a stream, river, or railway—and if the manufacturer
transfers his works to the country, he will rightly choose the most
convenient and advantageous site for them that offers, and other
arrangements will have to be made in concert with him.
Nevertheless, the factory or factories should be as far as possible
from the main centre, that is on the village or city outskirts. The
preferable position would lie between the north-east and south-west,
for the prevalent south-west wind will then carry away the smoke in
summer, when the villagers indulge in outdoor life, while the north
and easterly winds of winter will carry it over the village when they
are indoors. Screens of trees should be planted between the village
and the factories as soon as possible.
Plots for Houses.—As to the treatment of the plots for houses:
should the road cut into the land it need not necessarily be levelled,
but taken as it is; the gables will thus present a desirable variation of
level, and the ridge line will be less monotonous. An endeavour
should be made, however, always to get the plots not less than 18
ins. above the level of the crown of the road, otherwise the drainage
will be troublesome and expensive.
As soon as the house is erected, it is well to set hedges of thorn or
beech, both along the roadside and between the houses. Until these
are grown, the ordinary iron hurdle, or light-railed wooden fence,
might serve.
It is advisable to arrange the building plots so that the houses on
either side of the road do not come exactly opposite each other; the
houses should be so arranged as to face the open space opposite.
Gardens.—At Bournville the average garden-space allowed each
house is 600 square yards, this being found to be about as much as
the average man can well attend to. (This means there will be from
eight to twelve cottages to the acre.) The laying out is done prior to
the tenant’s occupation of the house. A description of the way the
Bournville gardens are laid out is given, with a plan, on page 23.
When the houses are placed at the end of the plot remote from the
road, any hard and fast lines in the style of the garden should be
avoided: apple and other fruit-trees, or an occasional kitchen-garden,
may be placed in a prominent position, for even the trim flower-
garden might be varied with advantage. A preference has already
been expressed for having the garden adjacent to the house rather
than the allotment garden at a distance, but at the same time the
latter plan may be sometimes forced upon us. Undoubtedly the
rivalry that is encouraged among gardeners congregated together in
allotment gardens is good and healthy, but the inconvenience to the
household of the distance between home and garden would suggest
the adoption of the former whenever it is possible, and even where
there is an allotment there should still be a small plot adjacent to the
house.
While endeavouring to get as much light and air space as possible
in the village, it will frequently be found necessary to erect cottages
in blocks of four, and sometimes of eight. In order to give adequate
garden-space, even to small houses, and not in long thin strips, the
frontage of the land will have to be broad; a rule should be made,
therefore, of spreading the houses laterally by arranging the
staircase of each house, not between the back and front rooms, but
between the houses. This will bring the outside houses nearer to the
extremity of the land, and will not only give each garden the desired
straightness and breadth, but afford a greater breadth of view upon it
from within.
In conclusion, it might be again stated that most of the remarks
under this head—which are mainly arranged from notes taken or
suggested during the planning and working out of the Bournville
Estate—are broad and suggestive rather than insistent, and it is
probable that the setting out of particular land will not admit of the
adoption of many of the principles here laid down.
BRADBURY, AGNEW & CO., LD., PRINTERS, LONDON AND TONBRIDGE.
TRANSCRIBER’S NOTE

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