DATABASE TEXT

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  GUIDELINES ON FOOD FORTIFICATION WITH
MICRONUTRIENTS FOR THE CONTROL OF MICRONUTRIENT
MALNUTRITION DRAFT   Department of Nutrition
for Health and Development World Health
Organization Geneva Lindsay Allen, Bruno de
Benoist, Omar Dary, Richard Hurrell (Editors)  
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• OBJECTIVES OF THE GUIDELINES
• To provide countries with guidance on benefits,
  planning, implementing, monitoring and evaluating
  a food fortification program.
• To make fortification safe, effective and
  sustainable as a public health intervention.

WHO/NHD
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CONTENTS Part I Role of food fortification in MNM
control Part II Public health significance of
MNM, and benefits from its control Part
III Fortificants characteristics, selection
criteria, and experience with fortification of
specific foods Part IV Key elements for
implementing safe, effective and sustainable
fortification programmes
WHO/NHD
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• I. ROLE OF FOOD FORTIFICATION Definitions
• Fortification is the addition of micronutrients
  to commonly eaten foods, beverages or condiments
• Here fortification also covers restoration
  (restoring nutrients removed by milling or
  processing) and substitution (sometimes called
  nutritional equivalence, which is addition of
  nutrients to a substitute product to the level in
  the food that the product is designed to
  resemble).
• The goal of fortification is to increase the
  micronutrient intake of an acceptable proportion
  of the population to an adequate level, without
  causing an unacceptable risk of excessive intake.

WHO/NHD
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• Types of fortification
• Mass fortification (main focus of the guidelines)
• Targeted fortification
• Open-market fortification
• Other types of fortification

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• Mass fortification
• or universal fortification
• Addition of MN to foods, beverages or condiments,
  commonly consumed by the general population
• Usually instigated, mandated and regulated by the
  government sector
• Required when the majority of the population has
  an unacceptable risk, in terms of public health,
  of being or becoming deficient in specific
  micronutrients
• Low intake or biochemical/clinical signs of
  deficiency
• Positive public health effect (folic acid
  fortification)

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• Targeted fortification
• Fortification of foods for specific groups
• Infants, young children, school-aged children,
  pregnant and lactating women, refugees and
  displaced persons (WFP) e.g. Incaparina,
  Progresa, Ali Alimentu
• These fortified foods need to supply a
  substantial proportion of daily MN intake
• Blended foods for refugees and displaced persons
  supply most of their protein and energy
  requirements
• Need to supply all or most MN as well due to lack
  of access to fresh foods (vegetables and fruits)

WHO/NHD
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• Open-market (voluntary) fortification
• Food manufacturers initiative
• Their aim is to improve public health profit
• Increasing in developing countries
• Public health benefits that can be expected
• Contribution to meeting MN requirements
  specially in societies where diet is based on
  many industrial-made foods.
• Supply MN that may be more difficult to add in
  adequate amounts through mass fortification (e.g.
  calcium, iron, several MN in breakfast cereals).

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Community and Household fortification

• Community/Village premix available to add during
  milling (but problems of quality control, costs
  etc.).
• Household complementary food supplements
  UNICEF and WHO have crushable and dispersible
  tablets also Sprinkles etc. Much more expensive.

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II. PUBLIC HEALTH SIGNIFICANCEEffectiveness
evaluations

• 1920, in Michigan reduced goiter from 40 to lt10
  due to the addition of iodine to salt.
• Sugar in Guatemala starting 1974, then other
  countries in Central America, controls vitamin A
  deficiency.
• In US, Fe fortification using FeSO4 of
  complementary foods associated with fall in
  anemia in lt5 y.o.
• Fortification of dry milk with Fe ascorbic acid
  in Chile rapidly reduced anemia in ID in infants
  and young children.
• Fe-EDTA in soy sauce in China reduced anemia in
  all age groups after 6 months.

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Efficacy trials vitamin A

• VA in oil was absorbed well in a rice based diet
  in Brazil.
• VA-fortified MSG in Philippines reduced child
  mortality, and improved growth and Hb.
• Preschoolers in Philippines consumed 24 g/d VA
  fortified margarine for 6 mo and prevalence of
  low serum retinol concentrations fell from 26 to
  10 (Solon 1996).
• VA fortified wheat flour fed as buns to Filipino
  schoolers for 30 mo halved with low liver
  stores.

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Efficacy trials - iron

• Fish sauce in Viet Nam reduced anemia and iron
  deficiency within 6 months. (NaFeEDTA)
• Curry powder in S. Africa improved Hb ferritin,
  and IDA in women fell from 22 to 5 in 2 years.
  (NaFeEDTA)
• Double fortification of salt with iron
  (micronized pyrophosphate) and iodine improved
  iron and iodine status of Moroccan schoolers
  (Zimmerman).

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Efficacy trials several MN

• Fortified biscuits with Fe, B-carotene and iodine
  improved status of these nutrients in S. African
  schoolers (and A and Fe status declined in
  holidays) (van Stujvenberg).
• Fortified beverage with 10 MN in Tanzania
  increased serum retinol and reduced iron
  deficiency in schoolers, and improved their
  growth (Latham)
• Fortified beverage with 12 MN in Botswana
  increased wt gain, MUAC, Fe, folate, riboflavin
  and zinc status (Abrams)

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III. FORTIFICANTSIodine fortification
Fortificant potassium iodide or potassium
iodate - stability problems
- fortification technically easy - 130
countries affected by IDD - 98 mandatory salt
iodization - 27-90 of households covered
major vehicle is salt
other vehicles bread, water, milk
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General comments on vitamin A fortification

• Fortification of oil/margarine recommended where
  intake
• gt 10g/d for cereal flours gt 20g/d.
• When intake lt 10g/d, fortification level too
  high (possibility of excessive intake, high
  cost, high losses).
• Spray-dried form of vitamin A is 4 times more
  expensive than oil soluble form.
• 20-50 overage to cover production/storage
  losses.

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General comments on iron fortification

• ? Iron fortification compounds in order of
  preference for staples are ferrous sulfate,
  ferrous fumarate, ferrous sulfate or fumarate
  encapsulated with partially hydrogenated oil.
  Electrolytic iron to be used as twice the level
  of ferrous sulfate and only in diets with low
  absorption inhibitors, otherwise NaFeEDTA.
  Ferrous bisglycinate in milk has shown positive
  results.
• The use of elemental iron powders other than
  electrolytic iron is not recommended.
• Fortified flours should be consumed in amounts
  larger than 100 g/day to detect some biological
  impact.

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IV. KEY ELEMENTSJustification and Design

• To provide ?97.5 of individuals in a population
  with an intake that meets their Estimated Average
  Requirement (EAR) for specific MN without
  exceeding their Tolerable Upper Intake Level
  (UL).
• i.e. the probability of nutrient inadequacy and
  excess must be acceptably low.
• Made possible by development of EARs and UL and
  improved understanding of their application
  (IOM). Also estimation of EARs for others
  (FAO/WHO).

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Constraints on MN addition
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We need to plan so that ?2.5 of the group has an
intake below the EAR
This will mean ??20 will not meet their RDA/RNI,
but fortification levels will be safer and more
realistic for population measures.
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Monitoring and Evaluation
VITAMIN PREMIX
Certificate of Quality (Food Control and Customs)
FOOD National or Imported
INDUSTRY MONITORING
Quality Control and Q. Assurance (Dept. of
Quality Control of Factories and Packers)
FORTIFIED FOOD (Factories or Packers)
IMPORTED FORTIFIED FOOD
Importation Warehouse
Factory Inspection (Corroborating trial) and
Technical Auditing (Government Food Control Unit)
Certificate of Conformity or Inspection (Corrobo
rating trial) (Food Control Dept. and Customs
FORTIFIED FOOD (Factories or Packers)
LEGAL MONITORING
Verification of Legal Compliance (Corroborating
trial in retail stores) (Food Control and Units
of Standards and/or Consumer Protection)
FORTIFIED FOOD (Distribution or Retail Stores)
Quality Auditing with Conformity
Assessment (Food Control/ witnesses)
FORTIFIED FOOD (Households))
Utilization Indicators (Presence of F.F. at
households)
HOUSEHOLD MONITORING
ADEQUACY EVALUATION
CONSUMPTION OF F.F. (Individuals, families)
Coverage Indicators (Amount and frequency)
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Examples of indicators of Performance
and Impact of FF Programs
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Cost Effectiveness

• Benefitcost of salt iodization 401
• Cost-effectiveness of vitamin A fortification
  could be 18/death averted (extremely low DCPDC
  II will consider interventions costing up to 1X
  GDP/capita)
• Benefitcost of iron fortification (wheat flour)
  81

Communications
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Limitations of fortification

• Does not substitute for a good quality diet
• May not reach the most disadvantaged groups
  living on the margins of the market economy
• Home produced staples or small processing
  operations do not allow fortification.
• Technological constraints due to
• Adverse sensory effects on the food vehicle
• Rice is difficult
• Potential risk of high intakes
• Interaction among MN if multiple fortification

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• Food Fortification is only one available
  strategy.
• Strategies available to control MNM
• Combination of interventions to correct nutrient
  intake (dietary approaches, supplementation,
  fortification and biofortification)
• Public health measures
• These approaches should be regarded as
  COMPLEMENTARY.
• In practice current strategies focus on
• Fortification
• Long history in industrialised countries
• Increasingly feasible in developing countries
• Supplementation
• Quickest intervention to implement to reduce MNM
• For VA, more sustainable than originally thought
  (vit A in EPI) but for other MN, limited
  effectiveness.

WHO/NHD