Large-scale food fortification (LSFF) is a cost-effective intervention that is widely implemented, but there is scope to further increase its potential. To identify gaps and opportunities, we first accessed the Global Fortification Data Exchange (GFDx) to identify countries that could benefit from new fortification programs. Second, we aggregated Fortification Assessment Coverage Toolkit (FACT) survey data from 16 countries to ascertain LSFF coverage and gaps therein. Third, we extended our narrative review to assess current innovations. We identified 84 countries as good candidates for new LSFF programs. FACT data revealed that the potential of oil/ghee and salt fortification is not being met due mainly to low coverage of adequately fortified foods (quality). Wheat, rice and maize flour fortification have similar quality issues combined with lower coverage of the fortifiable food at population-level (<50%). A four-pronged strategy is needed to meet the unfinished agenda: first, establish new LSFF programs where warranted; second, systems innovations informed by implementation research to address coverage and quality gaps; third, advocacy to form new partnerships and resources, particularly with the private sector; and finally, exploration of new fortificants and vehicles (e.g. bouillon cubes; salt fortified with multiple nutrients) and other innovations that can address existing challenges.
Background: Household coverage with iodized salt was assessed in 10 countries that implemented Universal Salt Iodization (USI).Objective: The objective of this paper was to summarize household coverage data for iodized salt, including the relation between coverage and residence type and socioeconomic status (SES).Methods: A review was conducted of results from cross-sectional multistage household cluster surveys with the use of stratified probability proportional to size design in Bangladesh, Ethiopia, Ghana, India, Indonesia, Niger, the Philippines, Senegal, Tanzania, and Uganda. Salt iodine content was assessed with quantitative methods in all cases. The primary indicator of coverage was percentage of households that used adequately iodized salt, with an additional indicator for salt with some added iodine. Indicators of risk were SES and residence type. We used 95% CIs to determine significant differences in coverage.Results: National household coverage of adequately iodized salt varied from 6.2% in Niger to 97.0% in Uganda. For salt with some added iodine, coverage varied from 52.4% in the Philippines to 99.5% in Uganda. Coverage with adequately iodized salt was significantly higher in urban than in rural households in Bangladesh (68.9% compared with 44.3%, respectively), India (86.4% compared with 69.8%, respectively), Indonesia (59.3% compared with 51.4%, respectively), the Philippines (31.5% compared with 20.2%, respectively), Senegal (53.3% compared with 19.0%, respectively), and Tanzania (89.2% compared with 57.6%, respectively). In 7 of 8 countries with data, household coverage of adequately iodized salt was significantly higher in high- than in low-SES households in Bangladesh (58.8% compared with 39.7%, respectively), Ghana (36.2% compared with 21.5%, respectively), India (80.6% compared with 70.5%, respectively), Indonesia (59.9% compared with 45.6%, respectively), the Philippines (39.4% compared with 17.3%, respectively), Senegal (50.7% compared with 27.6%, respectively) and Tanzania (80.9% compared with 51.3%, respectively).Conclusions: Uganda has achieved USI. In other countries, access to iodized salt is inequitable. Quality control and regulatory enforcement of salt iodization remain challenging. Notable progress toward USI has been made in Ethiopia and India. Assessing progress toward USI only through household salt does not account for potentially iodized salt consumed through processed foods.
Food-based approaches for controlling vitamin A deficiency and its consequences, such as increased mortality, more severe morbidity, and anemia, have become increasingly important, thus prompting a reassessment of the relation between vitamin A intake and status. A nutrition surveillance system in Central Java, Indonesia, assessed the vitamin A intake and serum retinol concentration of women with a child < or =24 mo old with a semiquantitative 24-h recall method that categorized vitamin A-containing foods into 3 categories of plant foods and into 2 categories of animal foods and identified portions as small, medium, or large. Median vitamin A intake was 335 retinol equivalents (RE)/d (n = 600) and vitamin A intake from plant foods was 8 times higher than from animal foods. Serum retinol concentration was related to vitamin A intake in a dose-response manner. The multiple logistic regression model for predicting the chance for a serum retinol concentration greater than the observed median (> or = 1.37 micromol/L) included physiologic factors, vitamin A intake from plant [odds ratio (95% CI) per quartile: 1st, 1.00: 2nd, 1.23 (0.75, 2.02); 3rd, 1.60 (0.97, 2.63); and 4th, 2.06 (1.25, 3.40)] and animal [1st and 2nd, 1.00; 3rd, 1.31 (0.86, 2.02); and 4th, 2.18 (1.40. 3.42)] foods, home gardening [(no, 1.00; yes, 1.71 (1.12, 2.60)], and woman's education level [< or =primary school, 1.00; > or =secondary school, 1.51 (1.02, 2.22)]. Despite the fact that plant foods contributed 8 times as much vitamin A as did animal foods, serum retinol concentrations did not reflect this large difference. Home gardening and woman's education level seemed to reflect longer-term consumption of vitamin A-rich plant and animal foods, respectively.
Background: There has been tremendous progress over the past 25 years to control iodine deficiency disorders (IDDs) through universal salt iodization (USI). In 2019, using the median urinary iodine concentration (MUIC), only 19 countries in the world are classified as iodine deficient; in contrast in 1993, using the total goiter rate (TGR), 113 countries were classified as iodine deficient. However, few analyses have tried to quantify the global health and economic benefits of USI programs, and the shift from TGR to MUIC as the main indicator of IDDs complicates assessment of progress. Methods: We used a novel approach to estimate the impact of USI on IDDs, applying a regression model derived from observational data on the relationship between the TGR and the MUIC from 24 countries. The model was used to generate hypothetical national TGR values for 2019 based on current MUIC data. TGR in 1993 and modeled TGR in 2019 were then compared for 139 countries, and using consequence modeling, the potential health and economic benefits realized between 1993 and 2019 were estimated. Results: Based on this approach, the global prevalence of clinical IDDs (as assessed by the TGR) fell from 13.1% to 3.2%, and 720 million cases of clinical IDDs have been prevented by USI (a reduction of 75.9%). USI has significantly reduced the number of newborns affected by IDDs, with 20.5 million cases prevented annually. The resulting improvement in cognitive development and future earnings suggest a potential global economic benefit of nearly $33 billion. However, 4.8 million newborns will be affected by IDDs in 2019, who will experience lifelong productivity losses totaling a net present value of $12.5 billion. Conclusions: The global improvements in iodine status over the past 25 years have resulted in major health and economic benefits, mainly in low-and middle-income countries. Efforts should now focus on sustaining this achievement and expanding USI to reach the continuing large number of infants who remain unprotected from IDDs.
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