Regulatory and Policy-Related Aspects of Calcium Fortification of Foods. Implications for Implementing National Strategies of Calcium Fortification

Abstract

Daily calcium intake is well below current recommendations in most low- and middle-income countries (LMICs). Calcium intake is usually related to bone health, however an adequate calcium intake has also been shown to reduce hypertensive disorders of pregnancy, lower blood pressure and cholesterol values, and to prevent recurrent colorectal adenomas. Fortification of foods has been identified as a cost-effective strategy to overcome micronutrient gaps in public health. This review summarizes regulatory aspects of fortification of commonly consumed foods with micronutrients, with an emphasis on calcium. We selected a convenient sample of 15 countries from different WHO regions and described the regulatory framework related to calcium fortification of staple foods. We assessed the relevant policies in electronic databases including the WHO Global database on the Implementation of Nutrition Action (GINA) for fortification policies and the Global Fortification Data Exchange Database, a fortification database developed and maintained by Food Fortification Initiative (FFI), Global Alliance for Improved Nutrition (GAIN), Iodine Global Network (IGN), and Micronutrient Forum. Food fortification with micronutrients is widely used in many of the selected countries. Most countries had national legislation for the addition of micronutrients to staple foods, especially wheat flour. These national legislations, that includes regulations and standards, can provide the framework to consider the implementation of adding calcium to the fortification strategies, including the selection of the adequate food vehicle to reach the targeted population at risk safely. The strategy to include calcium in the fortification mix in fortified staple foods seems promising in these countries. However, potential undesired changes on the organoleptic characteristics of fortified foods and products thereof, and operational feasibility at the manufacturing site should be evaluated by the stakeholders during the planning stage. Codex Alimentarius standards should be considered by regulators in order to assure adherence to international standards. While the selected countries already have established national regulations and/or standards for fortification of key staple food vehicles, and there are experiences in the implementation of fortification of some staple foods, national food intake surveys can help plan, design, and modify existing fortification programs as well as monitor food and nutrient consumption to assess risk and benefits.

Current calcium fortification experiences: a review

“…35,36 However, as mentioned previously, the UK is the only country with a mandated calcium fortification program at the national level for wheat flour. 46 However, a few countries have official regulations and/or food standards that provide guidance for voluntary fortification of foods with calcium, which can be implemented by the different food producers. 46 We conducted a thorough review of the literature and institutional webpages, such as Global Fortification Data Exchange and other sources, to gather data on the regulations for calcium fortification of staple foods in different countries.…”

“…When reviewing the national food fortification efforts that include calcium, we found that calcium may be added to certain staple foods, such as in wheat flour, maize flour or cornmeal, rice, and milk 35,36 . However, as mentioned previously, the UK is the only country with a mandated calcium fortification program at the national level for wheat flour 46 . However, a few countries have official regulations and/or food standards that provide guidance for voluntary fortification of foods with calcium, which can be implemented by the different food producers 46 .…”

Effect of Calcium Fortified Foods on Health Outcomes: A Systematic Review and Meta-Analysis

“…Nowadays, more than 130 countries have mandatory food fortification with micronutrients such as iodine, iron, iodine, folate, and vitamin A, however only one country, the UK, has mandatory flour fortification with calcium [ 56 , 57 ]. Even this, the existance of mandatory fortification of foods with other minerals in several countries provides a technological and legal framework that could facilitate the addition of calcium [ 58 ].…”

Calcium‐fortified foods in public health programs: considerations for implementation

“…16 Several countries have established specific regulations for calcium food fortification. 94 Some specify the amount and type of calcium that can be added depending on the food vehicle and other technical details. These regulations are either done proactively, to help promote general health, or reactively, to protect the health and safety of the population.…”

“…Fortifying foods with calcium must follow regulations and should be designed within the country's national strategy for the prevention and control of micronutrient deficiencies 16 . Several countries have established specific regulations for calcium food fortification 94 . Some specify the amount and type of calcium that can be added depending on the food vehicle and other technical details.…”