Provision of micronutrients in coexisting public health programs and risk of excessive intake: regulatory considerations

Abstract

Countries around the world have been implementing public health interventions to provide vitamins and minerals. There is a concern that the cumulative micronutrient contribution of coexisting programs, when targeting the same population, may exceed their safe levels of intake, thus potentially challenging the primum non nocere principle. We assessed the regulatory framework of such interventions and determined qualitatively whether there were provisions in the regulations that called for coordination among programs to ensure their innocuousness. Country cases from various WHO regions were selected for the study: (1) the Americas: Chile, Costa Rica, and Guatemala; (2) Africa: Malawi, Uganda, and Zambia; (3) South Asia: Bangladesh; and (4) the Western Pacific Region: China and the Philippines. We did not identify any provisions in the existing regulations requiring coordination mechanisms among interventions. However, in some countries, governments have established national micronutrient fortification commissions or alliances aimed to foster interprogram coordination. Their focus, however, has been mostly on the efficacy of the programs and less on their safety. A regulatory framework for coexisting micronutrient interventions should be comprehensive, accounting for all micronutrient sources and including regulatory provisions for coordination among programs.

Current calcium fortification experiences: a review

“…Because of the concerns of several nutritional programs occurring in parallel without proper monitoring, some experts have conducted thorough reviews to map these efforts. For example, a 2019 review identified all the micronutrient programs occurring in Bangladesh, Chile, China, Costa Rica, Guatemala, Malawi, Uganda, and Zambia 62 . Similarly, a review of the SMILING project, a transnational collaboration between Cambodia, Indonesia, Laos PDR, Thailand, and Vietnam, with academic European partners from Europe, conducted a mapping of current fortification programs in these five countries 63 .…”

Are Malawian diets changing? An assessment of nutrient consumption and dietary patterns using household-level evidence from 2010/11 and 2016/17

“…This may be due, at least in part, to supplementation or fortification efforts. The Government of Malawi mandates various fortification programs: wheat flour and maize meal which are industrially processed are fortified with various vitamins and minerals, including folic acid, iron, zinc, and vitamin A, while sugar and cooking oil are also fortified with vitamin A (Mejia, Kuo, and Beltran-Velazquez 2019). Unfortunately, the IHS surveys do not collect enough information to take fortification into account in assessing the adequacy of nutrient intake.…”

“…With regard to nutrient deficiencies, it highlights the need to reduce iron-deficiency anemia and eliminate vitamin B12, folate, and zinc inadequacies. Enforcing mandated micronutrient fortification is part of the Strategic Plan -industrially-processed wheat flour and maize meal are required to be fortified with folic acid, iron, zinc, and vitamin A, while sugar and cooking oil must be fortified with vitamin A (Mejia, Kuo, and Beltran-Velazquez 2019). In addition, micronutrient supplementation programs, particularly for children aged 6 to 24 months, are to be intensified as part of the public health efforts of government.…”

Micronutrient Fortification of Commercially Available Biscuits Is Predicted to Have Minimal Impact on Prevalence of Inadequate Micronutrient Intakes: Modeling of National Dietary Data From Cameroon

“…Theoretically, overlap in consumption of multiple sources of fortified foods could put some groups at risk of exceeding the UL if program design (e.g., selection of fortification levels) does not account for this overlap. In practice it is challenging to adapt the design of public health programs to take into account these changes to the food system because often there is no mechanism for tracking the composition of voluntarily fortified products ( 56 ). In these scenarios with combined LSFF and fortified biscuits, we did not see evidence that biscuit fortification would contribute to intakes above the UL at the modeled fortification levels.…”