Food Fortification in Public Health Policy

1
Food Fortification in Public Health Policy

• TH Tulchinsky MD MPH
• Braun SPH
• 11 Nov 2003

2
Essential Considerations

• Public health and medical responsibility
• Food industry and regulators involved
• Create demand - enriched foods, behavior changes
• Monitor compliance and ID rates
• National council on nutrition - academic and
  professional organizations and public reps
• Long term program
• Regulatory, monitoring and laboratory support

3
Public Health Nutrition Strategies

• Food based strategy
• Socio economic factors
• Food supply/costs
• Education
• Supplementation for target groups
• Women and children
• Elderly
• Fortification of basic foods
• Surveillance and monitoring

4
18-19th Century Breakthroughs

• Lind and scurvy 1747
• Lemon juice in Royal Navy, 1796
• Davy isolates sodium, potassium, calcium,
  magnesium, sulphur, boron, 1807
• Chatin shows iodine prevents goiter, 1850
• Takaki and beriberi, Japanese Navy, 1885
• Eijkman publishes cause of beriberi, 1897

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Low Cost Solutions to Eliminate Micronutrient
Malnutrition
4
3
Annual Per Capita Cost of Interventions
2
US Dollars
1
0
Iron
Iron Fort
.
Iodine
Iodine
Vit A
Vit A
Suppl
.
Suppl
.
Fort
.
Suppl
.
Fort
.
Source World Bank, 1994
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Relative Cost Effectiveness of Micronutrient
Interventions
Productivity Gained per US Expended

146
.
0

150

125

100

84
.
1

75

47
.
5

50

28
.
0

24
.
7

13
.
8

25

0
Fe Suppl
.
Fe Suppl
.
Iodine
Vit
.
A
Fe Fort
.
Vit
.
A
(
Wom
.)
(
Preg
.
Fort
.
Fort
.
Suppl
.
Wom
.)
Source UNICEF/UNU/WHO/MI, 1999
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Vital Amines

• 1900, nutrition - calories, fats, carbohydrates
  proteins
• 1912, Funk defines vital amines
• Rickets, scurvy, goiter, beriberi common in
  industrial countries
• Pellagra epidemic in southern US
• 1914, Goldberger of USPHS investigates pellagra
• 1922, McCollum and vitamin D in cod liver oil

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More on Vitamins

• 1931, Fluoride shown to prevent tooth decay
• 1932, Vitamin C and riboflavin isolated
• 1933, Williams - kwashiorkor as vitamin
  deficiency
• 1941, Prenatal diet and health of newborn
• 1945, Fluoridation of water Grand Rapids
• 1948, Vitamin B12 isolated
• 1949, Framingham study begins

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Key Landmarks

• Mortons iodized salt, 1924
• Louisiana - mandates vit B fortification of
  flour, 1928
• US federal mandate - enrichment of flour with
  vitamins B and iron, 1941
• UK and colonies same during WWII

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Preventing Goiter and Iodine Deficiency Disorders

• 1917, high US draftees rejected - goiter
• 1922-27, goiter rates fall from 39 to 9 by
  statewide prevention programs
• 1924, Mortons Iodized Salt (N America)
• 1979, Iodization mandatory in Canada
• 1980s, WHO - universal iodization of salt
• Many countries achieved iodization

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Iodine Fortification of Salt in the U.S.
Trend in Goiter Prevalence in Michigan
WHO Monograph Series N. 44
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Pellagra The 4 Ds

• Diarrhea, dermatitis, dementia, death
• Thought to be of infectious origin
• Common in prisons, mental institutions,
  sharecroppers in southern US
• Curable by dietary change (Goldberger)
• 1929, niacin found as essential factor
• 1906-1940, 3 million cases and 100,000 deaths
  attributed to pellagra

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Figure 2                                       
                                            
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Rickets

• 1921, rickets affects 75 of children in New York
  City schools
• Cod liver oil commonly used (middle class)
• 1940s, US fortifies milk with vitamin D
  dramatically reduces rickets incidence
• Canada fortifies milk 1940s, then refortifies
  resulting in increase in rickets in 1960s

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Global Burden of Micronutrient Deficiencies

• Iron deficiency - all ages
• Chronic undernutrition all ages
• Iodine deficiency pregnancy
• Vitamin A deficiency young children
• PEM young children
• Folic acid deficiency all ages

• 2 billion
• 1 billion
• 200 million
• 200 million
• 167 million
• Unknown

• Source WHO

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Iron Deficiency

• Commonest MND
• Affects survival, health and productivity
• Affects women in age of fertility
• Affects pregnancy and newborn
• Affects growth and cognitive development of
  infants and children
• Interaction with vitamin C deficiency

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Global Burden of Iron Deficiency

• Source WHO

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Benefits of PreventingIron Deficiency

• Benefits to children
• Improved behavioral and cognitive development
• Improved child survival (where severe anemia is
  common)
• Benefits to adolescents
• Improved cognitive performance
• Better iron stores for later pregnancies (females)

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• Benefits to Pregnant Women and Their Infants
• Decreased low birth weight and perinatal
  mortality
• Decreased maternal mortality and obstetrical
  complications (where severe anemia is common)
• Benefits to all Individuals
• Improved fitness and work capacity
• Improved cognition
• Increased immunity
• Lower morbidity from infectious disease

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Trends in Prevalence of Anemia in Low-income
U.S. Children, 12-17 Months Old
Hgb lt10.3 g/dL Yip et al., JAMA, 1987
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• Preschool children
• School age children
• and adolescents
• Non-pregnant women
• Pregnant women
• Adult men

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Prevalence of iron deficiency by income and
race/ethnicity, U.S., 1-4 year olds, 1988-94
Based on serum ferritin model NHANES III (Ogden
et al., 1998)
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US Federal Policy

• USDA extension programs
• 1921-29, US Maternal and Infancy Act - state
  health departments employ nutritionists
• 1930s, relief/commodity distribution
• 1941, enriched wheat flour with iron, vit B
• 1941, US establishes RDAs
• Food stamps, WIC, school lunch programs
• National nutrition surveys

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Canada 1979

• National nutrition survey 1971
• Geographic, social and ethnic deficiencies
• Process of consultation
• 1979 federal regulations, mandatory
• Vitamin A and D in all milk products
• Iodine in salt
• Vitamins B and iron in flour

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Epidemiologic Revolution 1960s-1980s

• Risk factors for chronic disease
• Health field concept
• Health for All
• Declining mortality from stroke and CHD, trauma
• Advances in drugs and diagnostics
• Control of infectious diseases
• Rapid increase in costs of care health system
  reform

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Nutrition Interactions

• Iodine Deficiency psychomotor retardation
• Iron Def Anemia and infectious diseases
• Iron promotes growth and development
• Vitamin A and infectious diseases e.g. measles
• Vitamin A promotes growth
• Folic acid prevents birth defects
• Folic acid with CVD, Alzheimers Disease
• Nutrition and cancer
• Nutrition and cardiovascular disease
• Nutrition and diabetes
• Nutrition in disease management

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Folic Acid and NTDs

• Pre pregnancy folic acid supplements prevent
  neural tube defects, 1980s
• Supplements to women in age of fertility achieves
  lt1/3 coverage, 1990s (US)
• FDA mandates fortification of enriched flour,
  from 1998
• Canada and UK also mandate folic acid
  fortification of flour
• New paradigm in public health

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Table Return to top. Figure
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Figure
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(No Transcript)
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Folic Acid and Heart Disease

• High homocysteine levels associated with excess
  CHD, birth defects, Alzheimers Disease
• Folic acid reduces high homocysteine
• Flour fortification effective in raising FA
  levels in population
• Clinical trials of folic acid and CHD underway
• New paradigm in public health nutrition

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Osteoporosis

• Aging of the population
• Vit D production in skin seasonal
• Sun varies by season and latitude even in sunny
  countries
• Fortification of calcium popularized
• Vitamin D lacking in raw milk
• Calcium, vitamin D, fluoride co-factors
• Fortifying milk products with Vit D needed

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Problems with Fortification Policy

• Antagonism to trends in North America
• European resistance e.g. EU
• Nutritionist focus on clinical approach
• WHO ambivalence/opposition
• Green attitudes
• Medical attitudes and lack of interest
• Resistance to mandatory medication
• Individual choice
• Clinical vs. population approaches
• Manufacturers and regulatory agency attitudes

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Progress

• Decreased contamination and food-borne disease
• Improved food handling methods - refrigeration
• Improved nutritional value of foods and crops
• Food fortification
• Identifying essential micronutrients
• Food-fortification programs eliminated rickets,
  goiter, pellagra in the US, Canada
• Folic acid and other new disease relationships
• Micronutrients as functional food elements
• Genetically engineered foods

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Conclusion

• Nutrition a major public health issue
• Affects MCH, infectious, non infectious disease
• High priority birth defects, IDA, IDD, CHD
• Fortification has low sex appeal vs. clinical
• Mandatory vs. voluntary false dilemma
• Requires concern, knowledge, advocacy and
  leadership
• Public health role

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Referents

• World Health Organization
• UNICEF
• CDC
• American Academy of Pediatrics
• American College Obstetrics and Gynecology
• Food and Drug Administration
• Health Canada