Food Fortification as Public Health Policy

TH Tulchinsky MD MPH

Braun SPH

24 November 2013

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WHO, FAO 2006

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Key Fortification issues

• Iodine – cretinism, Iodine deficiency disorders (IDD)• Iron – iron deficincy and anemia• Vitamin B complex (B1, B2, B3, B6, B9, B12)• Vitamin D – rickets, osteoporosis, and linked with

many medical conditions• Folic acid – pre pregnancy neural tube defects;

pregnancy macrocytic anemia• Others – calcium, selenium, zinc

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Essential Considerations

Micronutrient deficiency conditions widespread

Non mandatory enriched foods are costly and not available to the poor e.g. bread, milk, yoghurts, salt

Public health and medical responsibility

WHO and best practices standards

Regulatory, monitoring and laboratory support are governmental public health responsibilities

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Public Health Nutrition Strategies

• Education• 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

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18-19th Century Breakthroughs

• James Lind and scurvy 1747• Lemon juice mandatory in Royal Navy, 1796• Humphrey 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 (Nobel

Prize 1929, anti-neuritic vitamin)

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Vital Amines

• 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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Key Landmarks

• Iodized salt, 1924

• Louisiana - mandates vit B fortification of flour to control pellagra epidemic, 1928

• US federal mandate - enrichment of flour with vitamins B and iron, 1941

• Britain and colonies same during WWII

• Canada mandates fortification in 1979

• Folic acid found to prevent NTDs in 1990s 15

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IronSuppl.

Iron Fort. IodineSuppl.

IodineFort.

Vit ASuppl.

Vit AFort.

U . S . Dol

lars

Low Cost Solutions to Eliminate Micronutrient Malnutrition

Source: World Bank, 1994

Annual Per Capita Cost of Interventions

World Bank 1994 16

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 Morton’s Iodized Salt (N America)

• 1979 Iodization mandatory in Canada

• 1980s WHO - universal iodization of salt

• Most member countries achieved iodization

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Iodine Fortification of Salt in the U.S.: Trend in Goiter Prevalence in Michigan

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1924 1929 1951

Year

Per

cen

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WHO Monograph Series N.

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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 Returns

• Past decade vast increase in publications • Occurs in breast fed un-supplemented LBW

babies• High risk for newborns of dark skinned or

totally covered women in northern latitudes, or in winter-spring

• Low vitamin D levels found in all age groups in Israel (KH Maccabee)

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Osteoporosis

• Aging of the population, women> men• Vitamin D production in skin• Sun varies by season and latitude even in

sunny countries• Indoor occupations children and adults• 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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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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Trends in Prevalence of Anemia* in Low-income U.S. Children, 12-17 Months Old

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73 75 77 79 81 83

Birth Year

Per

cent

Program Enrollment

Follow-up

*Hgb <10.3 g/dLYip et al., JAMA, 1987 24

Preschool children

School age

children

and adolescents

Non-pregnant

women

Pregnant women

Adult men

1998www.cdc.gov/mmwr

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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

• Policy review 2005• Folic acid mandatory since 1998

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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 <1/3 coverage, 1990s (US)

• FDA mandates fortification of “enriched” flour, 1998 • Canada, Chile also mandate folic acid fortification of

flour from 1998• Preliminary reports of reduced NTD rates• Policy renewed 1995

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Trends in Wheat-Flour Fortification with Folic Acid and Iron --- Worldwide, 2004 to 2007

Figure

.Return to top

MMWR, 2008;5:8-10 28

NTDs, Spina Bifida and Anencephaly

• Serious birth defects • 1 of 1,000 pregnancies• 300,000 yearly worldwide• Increased consumption of folic acid

can prevent 50%-70%• Diet• Supplements• Fortification• All of the above

From NEJM 1999

Mulinare J. CDC. National Center on Birth Defects and

Developmental Disabilities, 200329

NTDs In Newfoundland Pre and Post FA Fortification

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NEJM 200731

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Fortification Status - June 2010

Fortification Status - June 2010

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UK Food Standards Agency

FSA recommends mandatory fortification of bread or flour with folic acid in order to reduce the risk of neural tube defects in foetuses.

Currently being considered by UK health ministers, following advice from the four Chief Medical Officers in the UK.

If approved, the relevant UK health departments will be responsible for producing implementation.

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.

Yetley E A Am J Clin Nutr 2008;88:558S. American Society for Nutrition-564S

Prevalence of low serum 25-hydroxyvitamin D concentrations from

the NHANES 2000–2004

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Conclusion

• Nutritional security - 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 advocacy !!!

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Reference/Sources

• World Health Organization

• UNICEF

• Centers for Disease Control, Atlanta NHANES

• American Academy of Pediatrics

• Food and Drug Administration

• GAIN

• Health Canada

• UK Food Standards Agency

• New Public Health chapter 8

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