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.
Using a predetermined set of criteria, including burden of anemia and neural tube defects (NTDs) and an enabling environment for large-scale fortification, this paper identifies 18 low- and middle-income countries with the highest and most immediate potential for large-scale wheat flour and/or rice fortification in terms of health impact and economic benefit. Adequately fortified staples, delivered at estimated coverage rates in these countries, have the potential to avert 72.1 million cases of anemia among non-pregnant women of reproductive age; 51,636 live births associated with folic acid-preventable NTDs (i.e., spina bifida, anencephaly); and 46,378 child deaths associated with NTDs annually. This equates to a 34% reduction in the number of cases of anemia and 38% reduction in the number of NTDs in the 18 countries identified. An estimated 5.4 million disability-adjusted life years (DALYs) could be averted annually, and an economic value of 31.8 billion United States dollars (USD) generated from 1 year of fortification at scale in women and children beneficiaries. This paper presents a missed opportunity and warrants an urgent call to action for the countries identified to potentially avert a significant number of preventable birth defects, anemia, and under-five child mortality and move closer to achieving health equity by 2030 for the Sustainable Development Goals.
Objectives: Recognizing that low iron stores pre-conception continue during pregnancy, the government of Chhattisgarh and Micronutrient Initiative (MI) implemented weekly IFA supplementation (WIFS) program from July 2011 till May 2012 among school-going adolescent girls in classes 9 to 12 (SG) and out-of-school adolescent girls aged 11-18 years (OG). The aim of this program was to demonstrate effective approaches of achieving high rates of coverage and utilization of WIFS among SG and OG. Methods: The project involved multi-department government coordination and was implemented through schools for SG and 'community based centres for women and children' -anganwadi centres (AWCs) -for OG. A cascade approach was adopted to train teachers, peer guides and anganwadi workers. Supervised weekly dose of enteric coated IFA was administered to over 95,000 adolescent girls in 424 schools and 6,832 AWCs after counselling for probable side-effects. MI facilitated supportive supervision, program reviews and completion of baseline and endline surveys. Results: 93.8% SG and 73% OG received free IFA tablets. 48.1% of SG and 31.4% of OG completed at least 80 % of the recommended dosage. Post side-effect counselling added to an incremental compliance of 15.4% to a full recommended weekly dose. There was 22.5% increase in the knowledge level among adolescent girls on atleast three causes and prevention of anaemia. Conclusions: Effective multi-department coordination, health and nutrition education and effective
Objectives Fortification is a common strategy to reduce the prevalence of iron deficiency anemia (IDA). Currently, manufacturers are able to fortify wheat flour with cheaper iron compounds with lower bioavailability, leading to less of an impact on IDA. Therefore, a method is needed for government agencies to monitor the type of iron added to flour. The objective was to develop a quick and simple method to qualitatively determine iron compounds commonly used for fortifying wheat flour. Methods Unfortified wheat flour was fortified with 40 ppm using these salts: ferric pyrophosphate (FePP), ferrous sulfate (FeSO4), ferrous citrate (FeC), ferrous fumarate (FeF), and sodium iron EDTA (NaFeEDTA), except for electrolytic iron (EFe) where 60 ppm was added. Iron salts were identified based on their magnetic property, solubility in water or acid, and oxidation state. EFe was identified by passing a magnet through the flour. Ferrous and ferric salts were identified using potassium thiocyanate (KSCN) in 3 N hydrochloric acid (HCl) with and without hydrogen peroxide (H2O2). Ferric salts (NaFeDTA and FePP) were identified using Ferrozine and ascorbic acid. Poor solubility of FeF in weak acid with KSCN was used to differentiate it from FeSO4 and FeC. Acidity testing with phenolphthalein and sodium hydroxide (NaOH) further differentiated FeC from FeSO4. Flour samples were tested in triplicates and blinded samples were tested independently. Results EFe from flour was visible on the magnet. In addition to producing red specks with KSCN, NaFeEDTA in water produced strong color with Ferrozine and ascorbic acid, unlike FePP. Using KSCN and H2O2, FeF did not produce pink color with 0.1 N HCl, unlike FeSO4 and FeC. Acidity testing differentiated FeSO4 and FeC; FeSO4 produced pink color with less NaOH than FeC. Blinded flour samples were independently and correctly identified to confirm the validity of the methods. Conclusions These quick, inexpensive, and reliable qualitative methods will be useful for agencies to identify the type of iron added to flour to monitor the quality of iron fortification strategies. Funding Sources Supported by Nutrition International through a grant from Global Affairs Canada.
Objectives Review literature and conduct a meta-analysis to quantify changes in hemoglobin (Hb) and anemia prevalence among women of childbearing age after fortification of wheat flour, maize flour, rice and oil (singly or combined). Methods Online databases were searched for English-language documents with no restrictions on location or publication date that included longitudinal, pre-post cross-sectional, efficacy and effectiveness studies. A Bayesian arm-based meta-analysis estimated mean change and probability of Hb and anemia improvement from 17 studies. Results were stratified by fortified food and nutrients added to food. Results There was a > 95% probability that fortified wheat flour improved Hb and reduced anemia; mean Hb increased by 3.39 g/L (95% Credible Interval (CI) –0.63, 7.17) and anemia decreased by 12.8 percentage points (pp) (95% CI –23, 0.9). Likewise, fortified rice had a > 65% probability of improving Hb and reducing anemia; mean Hb increased by 2.71 g/L (95% CI –4.88, 10.64) and anemia decreased by 16.9 pp (95% CI –81, 37.8). Conversely, fortified maize flour had < 45% probability of improving Hb and reducing anemia; mean Hb decreased by 2.88 g/L (95% CI−12.85, 7.24) and anemia increased by 13.5 pp (95% CI –133,164). There was a > 90% probability that fortifying maize flour, oil, rice, and/or wheat flour with iron, folic acid or multiple micronutrients (MM) improved Hb. Mean Hb increase was highest for iron fortification (3.93 g/L, 95% CI 0.50, 7.56), followed by folic-acid fortification (3.42 g/L, 95% CI –2.08, 9.56), and lowest for MM fortification (2.11 g/L, 95% CI 0.75, 3.68). There was a > 45% probability that fortifying with any nutrients reduced anemia. Mean anemia decrease was highest for iron at 17.3 pp (95% CI –78.2, 35), followed by folic acid at 7.2 pp (95% CI −32.5, 19.7); however, fortification with MM increased anemia by 1.2 pp (95% CI –9.8, 14.9). Conclusions There was a high probability of fortification increasing hemoglobin concentration if wheat flour or rice are fortified independently, and if foods are fortified with iron alone, folic acid alone, or a combination of multiple micronutrients. Anemia reductions were greatest for fortified wheat flour and rice and for foods fortified with iron and folic acid. Funding Sources Global Affairs Canada.
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