Food Fortification Initiative Research Articles

A global update on the status of prevention of folic acid-preventable spina bifida and anencephaly in year 2022.

Mandatory fortification of staple foods with folic acid is an effective public health strategy to prevent folic acid-preventable spina bifida and anencephaly (FAP SBA). We estimated the global proportion of FAP SBA prevented through mandatory folic acid fortification of cereal grains (i.e., wheat flour, maize flour, and rice). We used year 2022 data from the Food Fortification Initiative to identify countries (n = 69) with mandatory fortification of grains that includes folic acid. Sixty-eight countries were eligible for analysis with complete data. Proportion of FAP SBA prevention was modeled assuming >150 mcg/day of folic acid fortification protects against FAP SBA, reducing post-fortification prevalence to a lowest achievable level of 0.5 cases per 1000 births. Our analysis found that a total of 63,520 cases of FAP SBA were prevented in the year 2022 in 68 countries implementing mandatory folic acid fortification of grains with folic acid. This translated to a 23.7% prevention of all possible FAP SBA prevention globally. An excess of 204,430 cases of FAPSBA still occurred in over 100 countries where mandatory staple food fortification with folic acid is not implemented. Our study showed that only a quarter of all FAP SBA cases were averted through mandatory folic acid fortification in the year 2022; many countries are not implementing the policy, resulting in a large proportion of FAP SBA cases that can be prevented. Fortification will help countries with achieving 2030 Sustainable Development Goals on neonatal- and under-five mortality, disability, stillbirths, and elective terminations prevention, from FAP SBA.

Perspectives on ultra-processed foods as vehicles for food fortification

BackgroundThe rising popularity in low- and middle-income countries (LMICs) of ultra-processed foods (UPFs), defined by the Nova classification system, makes them an appealing option for food fortification initiatives to address micronutrient deficiencies in vulnerable populations. However, significant controversy surrounds this issue given that higher intake of UPFs is associated with a range of health risks including development of non-communicable diseases (NCDs). Scope and approachThis paper investigates the utility and extent to which UPFs may be used as vehicles of fortification to improve population health. The underlying mechanisms linking UPFs with disease are discussed and evaluated compared to the potential risks of eliminating them from fortification initiatives. A summary of the four main arguments most commonly cited in the debate over UPFs and their fortification are then reviewed. Key findings and conclusionsThe future of fortified UPFs needs more research to untangle the health effects of food processing, the involvement of the food industry in product reformulation, and a strengthening of regulation on production and labeling. This perspectives piece serves to stimulate further debate regarding the role processing should play in foods in general and how it should be considered by nutritional classification schemes to assess the healthfulness of foods.

A global update on the status of prevention of folic acid-preventable spina bifida and anencephaly in year 2020: 30-Year anniversary of gaining knowledge about folic acid's prevention potential for neural tube defects.

Spina bifida and anencephaly are major neural tube defects largely preventable through maternal periconceptional intake of folic acid. We estimated the global proportion of folic acid-preventable spina bifida and anencephaly (FAP SBA) prevented through mandatory folic acid fortification of cereal grains, including wheat flour, maize flour, and rice, at the end of year 2020, a time point marking the 30th anniversary of the publication of landmark British Medical Research Council (MRC) study providing unequivocal knowledge on folic acid's FAP SBA prevention potential. The Food Fortification Initiative database was used to identify countries with mandatory fortification policies with folic acid added to cereal grains. We examined the status of FAP SBA prevention assuming mandatory folic acid fortification at 200 mcg/day of folic acid protects against FAP SBA and reduces their prevalence to a minimum achievable rate of 0.5 cases/1000 live births. Our analysis showed that 61,680 FAP SBA cases were prevented in the year 2020 through mandatory folic acid fortification of cereal grains in 58 countries, translating to 22% prevention of total possible FAP SBA prevention globally. Many countries in Africa, Asia, and Europe are yet to implement fortification. In 2020, 30 years after the MRC study was published, 218,270 preventable FAP SBA cases still occurred globally. Global prevention efforts for FAP SBA are inadequate even after three decades of knowledge on their prevention. Universal mandatory fortification of staples should be urgently implemented to prevent thousands of FAP SBA and associated elective terminations, stillbirths, and child mortality.

Examining Heterogeneity of Food Fortification and Biofortification Business Models: Emerging Evidence for a Typology.

Efforts to address Micronutrient deficiencies (MNDs) in lower-and middle-income countries (LMICs) have been gaining pace in recent years. Commodities such as staple foods (e.g., cereals, roots, and tubers) and condiments (e.g., salt) have been targeted as ‘vehicles’ for fortification and biofortification through numerous projects and initiatives. To date, there have been mixed experiences with delivery and coverage with very little documented on the range of business models applied in different geographies, business conditions and polities and this makes classification and measurement of success and failure difficult. This research aims to address this gap in knowledge through proposing a typology that clarifies similarities (internal heterogeneity) and differences (external heterogeneity) between models and that can allow all types to be defined by the combination of attributes. Building on a comprehensive literature review; NVivo was used to code initiatives from 34 key references (955 cases in total) which have been grouped into 17 categories. Using non-metric multidimensional scaling (NMDS) we find evidence of four business model groupings that typify fortification initiatives: (1) Large-scale private, unregulated, (2) Mixed-Scale, private, unregulated (3) Large-scale, public-private, regulated; and (4) Large-scale, private, regulated. We characterise these four groups with country examples and suggest that this typology can help the discourse around viability of food fortification initiatives.

The Global Burden of Neural Tube Defects and Disparities in Neurosurgical Care

Despite the success of folic acid fortification programs, neural tube defects (NTDs) such as spina bifida, encephalocele, and anencephaly remain among the most substantial causes of childhood morbidity and mortality worldwide. Although these are complicated conditions that require an interdisciplinary approach to care, definitive treatment of survivable NTDs is often neurosurgical. Using Global Burden of Disease data, we examined the global burden of NTDs as related to a nation's wealth, health care quality, and access to neurosurgical care. We abstracted data for death by cause, years lived with disability (YLD), gross domestic product (GDP), United Nations geoscheme, Food Fortification Initiative participation, and Healthcare Access and Quality Index. We compared means using 1-way analysis of variance and proportions using Fisher exact tests, with statistical significance as α= 0.05. Seventeen of 20 (85%) nations with the most deaths caused by NTDs (P < 0.0001) and 15/20 (75%) nations with the highest YLD (P < 0.0001) were in the lowest GDP quartile. Deaths and YLD were negatively correlated with increasing GDP and Healthcare Access and Quality Index (P < 0.0001). The nations with the highest disease burdens also had the fewest neurosurgeons per capita. Despite the success of folic acid fortification programs, greater global public health efforts should be placed on improving access to neurosurgical care in low and middle-income nations through sustainable initiatives such as surgeon exchange programs and the establishment of neurosurgery residency training programs.

Enhancing nutrition specific interventions through public health policies and public-private partnerships in the Eastern Mediterranean Region: a desk review

Background: Public private partnerships (PPPs) in public health have been widely promoted as an effective tool for accelerating progress toward achieving the United Nation’s Sustainable Development Goals (SDGs), including SDG2 “to eliminate hunger”. Partnership with the private sector was found to be very instrumental in improving the nutritional status of poor and food-insecure people and promoting healthy lifestyles. In countries of the Eastern Mediterranean Region (EMR), PPPs for nutrition actions have been mainly driven by the United Nations (UN) and international development agencies to support low and middle-income countries in achieving better health outcomes. Despite the increased prominence of engaging the private sector in public health actions in the EMR, evidence on the role of the private sector in the design/implementation of these actions is still not documented. The objective of this study is to assess the role and contribution of the private sector in the design/implementation of nutrition-specific interventions addressing the double burden of malnutrition in countries from the EMR and identify the key factors for successful PPP implementation. Methods: The study design was descriptive using secondary data obtained from digital internet sources, including World Health Organization (WHO) databases, grey literature, and websites of the UN and international development agencies. Results: The desk review revealed that the private sector has played a sizable role in the implementation of food fortification initiatives and in the implementation of nutritional policies promoting healthy diets. The experience of the EMR shows the significant impact of government commitment, and the availability of national policies and systems for monitoring and enforcement on the sustainability and effectiveness of PPP-specific nutrition interventions. Conclusion: The study emphasizes the key actions recommended for governments to enhance the application of PPPs as a tool to accelerate the EMR’s progress toward achieving nutrition targets under SDG2 by 2030.

The Fallacy of Using Administrative Data in Assessing the Effectiveness of Food Fortification. Comment on: "Folic Acid Fortification and Neural Tube Defect Risk: Analysis of the Food Fortification Initiative Dataset. Nutrients 2020, 12, 247".

Our objective in this comment is to highlight several limitations in an ecological research study that was published in Nutrients by Murphy and Westmark (2020) in January 2020. The study used data from the Food Fortification Initiative (FFI) website, and applying an ecological study design, made an error of “ecologic fallacy” in concluding that “national fortification with folic acid is not associated with a significant decrease in the prevalence of neural tube defects (NTDs) at the population level”. We list study limitations that led to their erroneous conclusions, stemming from incorrect considerations regarding NTD prevalence, the average grain availability for a country, the fortification coverage in a country, the population reach of fortified foods within a country, and the absence of the consideration of fortification type (voluntary vs. mandatory), country-specific policies on elective terminations for NTD-affected pregnancies, stillbirth proportions among those with NTDs, and fortification implementation. FFI data are derived from many sources and intended for fortification advocacy, not for hypothesis testing. The flawed study by Murphy & Westmark (2020) in Nutrients promotes a confusing and incorrect message to stakeholders, misguides policy makers, and hinders progress in global NTD prevention through a cost-effective, safe, and effective intervention: the mandatory large-scale folic acid fortification of staple foods.

Reply to "The Fallacy of Using Administrative Data in Assessing the Effectiveness of Food Fortification. Comment on: Folic Acid Fortification and Neural Tube Defect Risk: Analysis of the Food Fortification Initiative Dataset. Nutrients 2020, 12, 247".

We would like to thank Kancherla et al [...].

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

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.

Folic Acid Fortification and Neural Tube Defect Risk: Analysis of the Food Fortification Initiative Dataset.

The United States implemented mandatory fortification of cereal grains with folic acid in 1998 to prevent neural tube defects (NTDs) during pregnancy. The health benefits of folate (vitamin B9) are well documented; however, there are potential risks of exceeding the upper tolerable limit, particularly in vulnerable populations. We conducted a population-based analysis of the Food Fortification Initiative dataset to determine the strength of the evidence regarding reports of decreased NTDs at the national level in response to mandatory folic acid fortification of cereal grains. We found a very weak correlation between NTD prevalence and the level of folic acid fortification, irrespective of the cereal grain fortified (wheat, maize or rice). Stratification of the data based on socioeconomic status (SES) indicated a strong linear relationship between reduced NTDs and better SES. We conclude that national fortification with folic acid is not associated with a significant decrease in the prevalence of NTDs at the population level.

The Regional assessment of the implementation of wheat flour fortification in the Eastern Mediterranean Region

Background: Wheat flour fortification is a preventive food-based approach aimed at reducing vitamin and mineral deficiencies or insufficiencies and their consequences. Fortification of industrially processed wheat flour, when appropriately implemented, is a simple, inexpensive and effective strategy for supplying vitamins and minerals to large segments of the world’s population.&#x0D; Objectives:&#x0D; The main objective of the study was to assess the current state of wheat flour fortification in the Eastern Mediterranean Region, identify common challenges and lessons learned from country experiences, outline the latest guidance on best practices, and make recommendations to advance appropriate wheat flour fortification in the Region.&#x0D; Methods:&#x0D; A questionnaire was designed to assess progress on the implementation of flour fortification in the Eastern Mediterranean Region according to key indicators. The questionnaire was circulated to the nutrition focal points within the Ministry of Health (MOH) in all countries of the Region. The data were extracted, analyzed and discussed in a regional Workshop organized by WHO in 2017. Data were verified or gaps were filled through other potential resources, such as MOH websites, WHO, World Bank, the Food Fortification Initiative and CDC.&#x0D; Results:&#x0D; The study shows that flour fortification has been widely used in countries of the Eastern Mediterranean Region. Most countries (17 of 22 in the Region) have some coverage of wheat flour fortified with iron and folic acid, and this is mandatory in 11 countries. Eight countries fortify flour with B-vitamins. Fortification with vitamin D, vitamin A and zinc is currently rare (two countries in each case). Quality control and monitoring of wheat flour is still a big challenge in all countries.&#x0D; Conclusion and recommendations:&#x0D; Considerable progress has been made in tackling micronutrient deficiencies, and wheat flour fortification has contributed to this. However, given that micronutrient deficiencies persist in the Region further progress is needed. Furthermore, countries need to review their policies and practices to ensure that they are in line with WHO guidance on best practice and that wheat flour fortification is being appropriately implemented.

Supplementation of micronutrients in children and food fortification initiatives in Sri Lanka: benefits versus risks.

In recent decades, Sri Lanka has made substantial progress in reducing the burden of micronutrient deficiencies in children by the provision of vitamin A megadose and micronutrient supplementation programs for children of 6-23 months, along with universal iodization of salt. Consumption of voluntarily fortified foods by children was also considerably increased. The objective of our study here was to review such interventions, which are beneficial in childhood, and to assess the risk of toxicity due to excessive intakes of iron, vitamin A, and iodine. Our analysis was performed using data from two national micronutrient surveys, market surveys, and key informant interviews. Data on coverage, usage, and nutrient content of certain foods were compiled to gauge consumption of iron, vitamin A, and iodine among children. We found that the severity of anemia and vitamin A and iodine deficiencies declined from moderate-to-severe and that supplementation and fortification can lead to an excess of vitamin A that may cause toxicity, while iron and iodine deficiency appears to be no longer a public health concern in Sri Lanka. We recommend review and scaling back of national supplementation programs and monitoring of fortification initiatives to prevent micronutrient toxicity in the future.

Vitamin B12 added as a fortificant to flour retains high bioavailability when baked in bread

Vitamin B12 deficiency and depletion are common world-wide, particularly in populations that consume low amounts of animal source foods. WHO and the Food Fortification Initiative recommend that wheat flour be fortified with vitamin B12 in regions where intake of B12 is low. The purpose of this pilot study in five participants was to determine if fortification of flour with B12 produced a bread product with intact B12 still present and to determine if healthy elderly absorb sufficient B12 from bread fortified in this manner. High-purity crystalline 14C-B12 was dissolved in water and added to flour (2 µg B12/100 g flour) in a bread maker and made into rolls (average 1.17 kBq (31.5 nCi) 14C-B12 in a total of 0.8 µg B12 per roll). Excess 14C first appeared in plasma 4 h after ingestion of the 14C fortified bread and plasma levels returned almost to background by 72 h. Measurement of 14C in plasma verified that the dose was absorbed into the systemic circulation. The cumulative % dose recovered in urine was 4.8–37.0% (mean = 20.1%). Most of the 14C label in the stool appeared by day 4, and the cumulative % dose recovered in stool was 24.5–43.0% (mean = 31.8%). Bioavailability among the 5 participants, calculated by subtracting the sum of urinary and fecal 14C excretion from the administered dose, was 28.4–63.7% (mean = 48.0%). This study showed that when B12 is added as a fortificant to flour it survives the fermentation and baking processes, and retains ∼50% bioavailability when fed in small doses to healthy subjects. The Recommended Dietary Allowance of B12 for adults is 2.4 µg/d. This recommendation assumes that usual bioavailability of low doses of the vitamin in the crystalline form is 60%, while for the same amount in foods such as meat and fish it is 50%. Our pilot study shows that B12 added to bread as a fortificant in flour was absorbed as well as it is from endogenous food sources such as meat and fish.

Large-Scale Food Fortification and Biofortification in Low- and Middle-Income Countries: A Review of Programs, Trends, Challenges, and Evidence Gaps.

BackgroundFood fortification and biofortification are well-established strategies to address micronutrient deficiencies in vulnerable populations. However, the effectiveness of fortification programs is not only determined by the biological efficacy of the fortified foods but also by effective and sustainable implementation, which requires continual monitoring, quality assurance and control, and corrective measures to ensure high compliance.ObjectiveTo provide an overview of efficacy, effectiveness, economics of food fortification and biofortification, and status of and challenges faced by large-scale food fortification programs in low- and middle-income countries (LMIC).MethodsA literature review of PubMed publications in English from 2000 to 2017, as well as gray literature, targeting nongovernmental organizations whose work focuses on this topic, complemented by national reports and a “snowball” process of citation searching. The article describes remaining technical challenges, barriers, and evidence gap and prioritizes recommendations and next steps to further accelerate progress and potential of impact.ResultsThe review identifies and highlights essential components of successful programs. It also points out issues that determine poor program performance, including lack of adequate monitoring and enforcement and poor compliance with standards by industry.ConclusionsIn the last 17 years, large-scale food fortification initiatives have been reaching increasingly larger segments of populations in LMIC. Large-scale food fortification and biofortification should be part of other nutrition-specific and nutrition-sensitive efforts to prevent and control micronutrient deficiencies. There are remaining technical and food system challenges, especially in relation to improving coverage and quality of delivery and measuring progress of national programs.

Characterizing the pH-Dependent Release Kinetics of Food-Grade Spray Drying Encapsulated Iron Microcapsules for Food Fortification

Iron deficiency is the primary cause of many widespread nutritional diseases including anemia, pregnancy complications, and infant mortality. Release kinetics of iron premixes to be mixed with food items like salt, rice, and tea is a key research objective of many globally active iron fortification efforts. Iron release kinetics of microcapsules of two reverse-enteric coating materials (chitosan and Eudragit EPO) encapsulating various amounts of ferrous sulfate (10–40% of total other solids) were done at three pH values (1, 4, 7) for 2 hours. Chitosan and Eudragit microcapsules contained 2.8–5.3% (w/w) and 1.7–9.6% (w/w) iron, respectively, depicting higher iron loading capacity of Eudragit microcapsules. More than 90% iron was released from most samples within 30 min under stomach conditions (pH 1) and less than 15% iron was released in 2 h under ambient conditions (pH 7), showing suitability of both chitosan and Eudragit EPO as reverse-enteric coatings for iron encapsulation. In terms of reverse-enteric behavior (RE), Eudragit EPO (RE = 2.4) was found to be slightly better than chitosan, suggesting the use of fillers in future research. Higuchi model and Hixson-Crowell model were found to best fit the data, suggesting a transport phenomenon governed by both (a) the diffusion process through the coating material and (b) the dissolution phenomenon resulting in decrease in size of the capsules. Results from this study shall provide guidance for technology development aspects of various food fortification initiatives and an understanding of the iron release from these fortificants during the food preparation and digestion stages.

Global Birth Prevalence of Spina Bifida by Folic Acid Fortification Status: A Systematic Review and Meta-Analysis

Background. Birth defects remain a significant source of worldwide morbidity and mortality. Strong scientific evidence shows that folic acid fortification of a region’s food supply leads to a decrease in spina bifida (a birth defect of the spine). Still, many countries around the world have yet to approve mandatory fortification through government legislation. Objectives. We sought to perform a systematic review and meta-analysis of period prevalence of spina bifida by folic acid fortification status, geographic region, and study population. Search methods. An expert research librarian used terms related to neural tube defects and epidemiology from primary research from 1985 to 2010 to search in EMBASE and MEDLINE. We searched the reference lists of included articles and key review articles identified by experts. Selection criteria. Inclusion criteria included studies in English or French reporting on prevalence published between January 1985 and December 2010 that (1) were primary research, (2) were population-based, and (3) reported a point or period prevalence estimate of spina bifida (i.e., prevalence estimate with confidence intervals or case numerator and population denominator). Two independent reviewers screened titles and abstracts for eligible articles, then 2 authors screened full texts in duplicate for final inclusion. Disagreements were resolved through consensus or a third party. Data collection and analysis. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses, or PRISMA, abstracting data related to case ascertainment, study population, folic acid fortification status, geographic region, and prevalence estimate independently and in duplicate. We extracted overall data and any subgroups reported by age, gender, time period, or type of spina bifida. We classified each period prevalence estimate as “mandatory” or “voluntary” folic acid fortification according to each country’s folic acid fortification status at the time data were collected (as determined by a well-recognized fortification monitoring body, Food Fortification Initiative). We determined study quality on the basis of sample representativeness, standardization of data collection and birth defect assessment, and statistical analyses. We analyzed study-level period prevalence estimates by using a random effects model (α level of &lt; 0.05) for all meta-analyses. We stratified pooled period prevalence estimates by birth population, fortification status, and continent. Results. Of 4078 studies identified, we included 179 studies in the systematic review and 123 in a meta-analysis. In studies of live births (LBs) alone, period prevalences of spina bifida were (1) lower in geographical regions with mandatory (33.86 per 100 000 LBs) versus voluntary (48.35 per 100 000 LBs) folic acid fortification, and (2) lower in studies of LBs, stillbirths, and terminations of pregnancy in regions with mandatory (35.22 per 100 000 LBs) versus voluntary (52.29 per 100 000 LBs) fortification. In LBs, stillbirths, and terminations of pregnancy studies, the lowest pooled prevalence estimate was in North America (38.70 per 100 000). Case ascertainment, surveillance methods, and reporting varied across these population-based studies. Conclusions. Mandatory legislation enforcing folic acid fortification of the food supply lags behind the evidence, particularly in Asian and European countries. This extensive literature review shows that spina bifida is significantly more common in world regions without government legislation regulating full-coverage folic acid fortification of the food supply (i.e., Asia, Europe) and that mandatory folic acid fortification resulted in a lower prevalence of spina bifida regardless of the type of birth cohort. African data were scarce, but needed, as many African nations are beginning to adopt folic acid legislation.

Global Birth Prevalence of Spina Bifida by Folic Acid Fortification Status: A Systematic Review and Meta-Analysis.

Birth defects remain a significant source of worldwide morbidity and mortality. Strong scientific evidence shows that folic acid fortification of a region's food supply leads to a decrease in spina bifida (a birth defect of the spine). Still, many countries around the world have yet to approve mandatory fortification through government legislation. We sought to perform a systematic review and meta-analysis of period prevalence of spina bifida by folic acid fortification status, geographic region, and study population. An expert research librarian used terms related to neural tube defects and epidemiology from primary research from 1985 to 2010 to search in EMBASE and MEDLINE. We searched the reference lists of included articles and key review articles identified by experts. Inclusion criteria included studies in English or French reporting on prevalence published between January 1985 and December 2010 that (1) were primary research, (2) were population-based, and (3) reported a point or period prevalence estimate of spina bifida (i.e., prevalence estimate with confidence intervals or case numerator and population denominator). Two independent reviewers screened titles and abstracts for eligible articles, then 2 authors screened full texts in duplicate for final inclusion. Disagreements were resolved through consensus or a third party. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses, or PRISMA, abstracting data related to case ascertainment, study population, folic acid fortification status, geographic region, and prevalence estimate independently and in duplicate. We extracted overall data and any subgroups reported by age, gender, time period, or type of spina bifida. We classified each period prevalence estimate as "mandatory" or "voluntary" folic acid fortification according to each country's folic acid fortification status at the time data were collected (as determined by a well-recognized fortification monitoring body, Food Fortification Initiative). We determined study quality on the basis of sample representativeness, standardization of data collection and birth defect assessment, and statistical analyses. We analyzed study-level period prevalence estimates by using a random effects model (α level of < 0.05) for all meta-analyses. We stratified pooled period prevalence estimates by birth population, fortification status, and continent. Of 4078 studies identified, we included 179 studies in the systematic review and 123 in a meta-analysis. In studies of live births (LBs) alone, period prevalences of spina bifida were (1) lower in geographical regions with mandatory (33.86 per 100,000 LBs) versus voluntary (48.35 per 100,000 LBs) folic acid fortification, and (2) lower in studies of LBs, stillbirths, and terminations of pregnancy in regions with mandatory (35.22 per 100,000 LBs) versus voluntary (52.29 per 100,000 LBs) fortification. In LBs, stillbirths, and terminations of pregnancy studies, the lowest pooled prevalence estimate was in North America (38.70 per 100,000). Case ascertainment, surveillance methods, and reporting varied across these population-based studies. Mandatory legislation enforcing folic acid fortification of the food supply lags behind the evidence, particularly in Asian and European countries. This extensive literature review shows that spina bifida is significantly more common in world regions without government legislation regulating full-coverage folic acid fortification of the food supply (i.e., Asia, Europe) and that mandatory folic acid fortification resulted in a lower prevalence of spina bifida regardless of the type of birth cohort. African data were scarce, but needed, as many African nations are beginning to adopt folic acid legislation.

A Statistical Analysis of Food fortification scheme

Food Fortification Initiative was launched with the objective of eliminating the problem of wide spread malnutrition within the State of Gujarat. The aim was to penetrate all the households and bring about a change in the consumables being used. The State Government and its agencies, along with the private partners joined hands to launch this initiative. The primary objective of the project was  To study the awareness and acceptance level among consumers about the fortified wheat flour.  To gauge the effectiveness of the initiative of fortification of wheat flour and recommend ways to improve their efficacy. The scope of this project was restricted to Ahmedabad city and only wheat flour fortification scheme was considered out of different food fortification schemes. A survey of 568 Public Distribution scheme (PDS) consumers, 23 PDS owners and 39 Chakki owners was undertaken in the city of Ahmedabad using multi stage sampling. After analyzing the data considering the objectives of the projects, observations and conclusions were made. Recommendations were given on the basis of the findings of the project to make the fortification scheme for effective and acceptable.

Regulatory Monitoring Systems of Fortified Salt and Wheat Flour in Selected Asean Countries

Considerable efforts have been made over the past decade to address vitamin and mineral deficiencies. An increasing number of countries in the Association of Southeast Asian Nations (ASEAN) are adopting mandatory food fortification as one of the primary strategies to overcome these deficiencies. Experience shows that fortified foods can reach large parts of the population, including the poor, if the fortification is done on a mandatory rather than a voluntary basis and if the food vehicle is widely consumed. To review the importance of regulatory monitoring as an essential component of food fortification efforts in selected ASEAN countries, with special focus on the available information on regulatory monitoring systems for iodized salt and fortified wheat flour. The role of regulatory monitoring in strengthening food fortification programs was discussed during a joint regional meeting of the World Health Organization, UNICEF, the Flour Fortification Initiative, the Global Alliance for Improved Nutrition, the Micronutrient Initiative, and the World Bank on regulatory monitoring of salt and wheat flour fortification programs in Asia, which took place in Manila, Philippines, on 27-29 September 2011. This paper reviews the regulatory monitoring systems of selected ASEAN countries that participated in this meeting. Problems and challenges in regulatory monitoring systems for iodized salt and fortified wheat flour in selected ASEAN countries are identified, and a description of the role of regulatory monitoring in strengthening food fortification initiatives, particularly of salt and flour, and highlights of areas for improvement are presented. Regulatory monitoring consists of monitoring activities conducted at the production level, at customs warehouses, and at retail stores by concerned regulatory authorities, and at the production level by producers themselves, as part of quality control and assurance efforts. Unless there are appropriate enforcement and quality assurance mechanisms in place to stimulate compliance by food producers, i.e., regulatory monitoring, having national legislation will not necessarily lead to increased coverage of fortified products and associated outcomes.

Folic acid food fortification in Canada.

By January 1998, most Canadian cereal grains (e.g., white flour) were being fortified with folic acid, with a large percentage being fortified by mid-1997. This was in compliance with both American and Canadian mandatory fortification deadlines of January and November 1998, respectively. It was estimated that between 0.1 to 0.2 mg of additional synthetic folic acid per day would be provided through this initiative, the goal of which was to lower the rate of neural tube defects (NTD). The current report outlines some of the changes to the health status of Canadians in relation to its folic acid food fortification initiative.