Fortification Policy Research Articles

Voluntary food fortification policy in Australia: did 'formal' stakeholder consultation influence the outcome?

This research aimed to understand how the policy was represented as a 'problem' in food regulatory decision-making in Australia, and the implications for public health nutrition engagement with policy development processes. Bacchi's 'what's the problem represented to be?' discourse analysis method was applied to a case study of voluntary food fortification policy (VFP) developed by the then Australia and New Zealand Food Regulation Ministerial Council (ANZFRMC) between 2002 and 2012. As a consultative process is a legislated aspect of food regulatory policy development in Australia, written stakeholder submissions contributed most of the key documents ascertained as relevant to the case. Four major categories of stakeholder were identified in the data; citizen, public health, government and industry. Predictably, citizen, government and public health stakeholders primarily represented voluntary food fortification (VF) as a problem of public health, while industry stakeholders represented it as a problem of commercial benefit. This reflected expected differences regarding decision-making control and power over regulatory activity. However, at both the outset and conclusion of the policy process, the ANZFRMC represented the problem of VF as commercial benefit, suggesting that in this case, a period of 'formal' stakeholder consultation did not alter the outcome. This research indicates that in VFP, the policy debate was fought and won at the initial framing of the problem in the earliest stages of the policy process. Consequently, if public health nutritionists leave their participation in the process until formal consultation stages, the opportunity to influence policy may already be lost.

Promoting Recall and Preserving the Historical Authenticity of Data Used to Investigate Food Regulatory Policy in Australia

This article reports on research methodology used for a case study investigating public health nutrition engagement in food regulatory policy processes in Australia. It aims to explore methods used and outline a model for how researchers can promote participant recall and accuracy. A set of key documents identified as relevant to voluntary food fortification policy (VFP) were analysed using Bacchi’s ‘What’s the problem represented to be?’ approach. The results informed a series of present-day, semi-structured, in-depth telephone interviews with experts in VFP. The major epistemological difficulty was the necessary reliance upon participant memory. Consequently, oral history methods were used to aid key informant recall. Several participants noted a benefit for their recollection of events from the tools employed. The experiences and approaches outlined in this article contribute to the toolkit needed when investigating historical events and may provide a useful model for other nutrition-related policy research.

Serum folate levels and cognitive performance in the ELSA-Brasil baseline assessment.

Most studies that analyze the association between serum folate levels and cognitive function either restrict their assessments to specific clinical scenarios or do not include middle-aged individuals, to whom strategies for preventing cognitive impairment may be more feasible. To examine the association between serum folate levels and cognitive function in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) baseline assessment. Data from 4,571 ELSA-Brasil participants who live in the state of São Paulo, aged 35-74 years, were analyzed. The word list learning, delayed recall, word recognition, verbal fluency, and Trail Making Test Part B consisted in the cognitive tests. For each test, age, sex, and education-specific standardized scores and a global cognitive score were calculated. Crude and adjusted linear regression models were used to examine the associations of serum folate levels with cognitive test scores. In multivariable-adjusted models, serum folate was not associated with global cognitive score (β=-0.043; 95% confidence interval [95%CI] -0.135 to 0.050 for lowest vs. highest quintile group), nor with any cognitive test performance. We did not find associations between serum folate and global cognitive scores in subgroups stratified by age, sex, or use of vitamin supplements either. We did not find significant associations between serum folate and cognitive performance in this large sample, which is characterized by a context of food fortification policies and a consequent low frequency of folate deficiency. Positive results from previous studies may not apply to the increasingly common contexts in which food fortification is implemented, or to younger individuals.

A 2019 global update on folic acid-preventable spina bifida and anencephaly.

Mandatory folic acid fortification of staples is a proven intervention to prevent spina bifida and anencephaly, two life-threatening and disabling neural tube defects. We estimated the global proportion of folic acid-preventable spina bifida and anencephaly (FAP SBA) prevented through mandatory folic acid fortification of wheat and/or maize flour in 2019. Using data from the Global Fortification Data Exchange, we identified countries with mandatory fortification policies that required at least 1.0 ppm folic acid be added to wheat and/or maize flour and had information on percentage of industrially milled flour that is fortified. We built FAP SBA prevention models assuming mandatory folic acid fortification at 200 μg/day of folic acid fully protects against FAP SBA and would lower the prevalence neural tube defects to 0.5 per 1,000 live births. In 2019, 56 countries met our criteria for mandatory folic acid fortification of wheat (n = 56 countries) and/or maize (n = 15 countries) flour and with complete data for our modeling. Overall, our prevention model estimated that 65,380 FAP SBA cases were prevented in 2019 through folic acid fortification of wheat and/or maize flour. We estimated the current global prevention proportion of all preventable FAP SBA cases worldwide to be at 23% of total possible prevention. Global prevention efforts for FAP SBA are slow and have stalled. Mandatory fortification should be urgently implemented in all countries to prevent epidemics of FAP SBA, and to achieve health-related Sustainable Development Goals for year 2030 by reducing child mortality due to preventable FAP SBA.

Awareness, knowledge and the factors that affect the use of folic acid among pregnant and non-pregnant women in the reproductive age in a selected area in Colombo district, Sri Lanka

<strong>Background: </strong>The prevalence of neural tube defects in Sri Lanka is estimated to be 1.21 per 1000 births. According to the WHO, programs to increase folic acid (FA) consumption among women of reproductive age may benefit countries where the NTD rate is higher than 0.6/1,000 live births. Food fortification is an effective method but there is still no mandatory fortification policy in Sri Lanka. Therefore, improving knowledge and voluntary use of FA remains a high priority. The study aimed to determine the awareness and knowledge on FA among pregnant and non pregnant women. <strong> </strong> <strong>Methods: </strong>A comparative cross-sectional study was conducted among 400 pregnant and 400 non-pregnant women aged 18-45 years from Colombo District in Sri Lanka. Data were collected using an anonymous, standardized, interviewer administered questionnaire, which included questions about socio-demographic data, obstetric history, FA knowledge and use. <strong> </strong> <strong>Results: </strong>FA awareness and knowledge on its pre-conceptional use were significantly low among non-pregnant women younger than 25 years (OR=0.120, 95% CI=0.068-0.211, p=0.000; OR=0.153, 95% CI=0.090-0.262, p=0.000). Pregnant women with knowledge that FA prevents birth defects were significantly more likely to take FA during pregnancy (OR=10.760, 95% CI=1.244-93.068, p=0.007) and the pre-conceptional period (OR=1.807, 95% CI=1.172-2.786, p=0.007). Women who received information from field clinics were significantly more likely to have FA awareness (OR=4.779, 95% CI=0.913-25.021, p=0.042), knowledge on pre-conceptional use of FA (OR=2.972, 95% CI=1.179-7.491, p=0.016) and took FA during pregnancy (OR=39.773, 95% CI=4.542-348.271, p=0.000). Those who received information from home visits were significantly more likely to have knowledge on the role of FA in preventing birth defects (OR=1.958, 95% CI=1.133-3.384, p=0.015), took FA during their pregnancy (OR=15.102, 95% CI=1.743-130.841, p=0.001) and in the pre-conceptional period (OR=2.117, 95% CI=1.316-3.405, p=0.002). Women who got information through media were also significantly more likely to have knowledge on the role of FA in preventing birth defects. (OR=2.487, 95% CI=1.006-6.149, p=0.042). <strong> </strong> <strong>Conclusions: </strong>Health education campaigns have to be specifically targeted for younger women from ethnic minorities and from low household income families. Field clinics and home visits from public health midwives have been a significant sources of information and media campaigns can be an effective means of promoting health education regarding use of preconceptional folic acid.

Inadequate vitamin D intake among pregnant women in Malaysia based on revised recommended nutrient intakes value and potential dietary strategies to tackle the inadequacy.

BACKGROUND/OBJECTIVESRecently, the recommended nutrient intakes (RNI) for vitamin D for Malaysian aged 1–70 yrs has been revised from 5 µg/day to 15 µg/day. This study is aimed to assess the adequacy of vitamin D intake based on revised RNI and to recommend several dietary strategies to increase total vitamin D intake.SUBJECTS/METHODSVitamin D intake from both food and supplement of 217 pregnant women was assessed using a validated food frequency questionnaire. Hypothetical effect of expanded supplementation and food fortifications strategies were modelled using the consumption data.RESULTSThe results revealed that more than half (67.7%) of pregnant women had inadequate vitamin D intake (RNI < 15 µg/day). The modelling results demonstrated the potential of universal provision of 10 µg/day of multivitamins supplements in increasing vitamin D intake. Moreover, mandatory fortification of both milk and malted drink at single level of 5 µg/serving would lead to increase in vitamin D intake of Malaysians, particularly pregnant women.CONCLUSIONSThe outcome of this study can be used as a reference for public health professionals to re-evaluate the existing Malaysian food fortification policies and supplementation recommendation for vitamin D for pregnant women.

A two-stage stochastic winner determination model integrating a hybrid mitigation strategy for transportation service procurement auctions

Disruption is one of the important and challenging factors in transportation service procurement auctions. Existing winner determination models tend to ignore bidders’ disruption risks and its dire consequences. This paper particularly studies a revised winner determination problem with disruption risks of bidders for a fourth party logistics (4PL) provider to purchase transportation services via combinatorial reverse auctions. Integrating a hybrid mitigation strategy that includes fortification, reservation and outside option policies to deal with disruptions, a new two-stage stochastic winner determination model is constructed. Based on the characteristics of the deterministic equivalent reformulation, a scenario-based approximation approach is developed as solution method. An upper bound can be obtained by using a scenario reduction approach, and a lower bound can be derived by employing a problem-based relaxation method or an efficient dual decomposition Lagrangian relaxation approach. Numerical experiments are conducted to illustrate the effectiveness and applicability of the proposed model and method, since the gap between the upper bound and lower bound is small. Comparison analysis indicates that our strategy is better than some known strategies, and would have a more significant influence on cost minimization of the 4PL as the probability of disruption becomes higher. Managerial implications are drawn for 4PLs to provide high quality of transportation services under disruptions.

In-Country Method Validation of a Paper-based, Smartphone-assisted Iron Sensor for the Food Fortification Programs

Abstract Objectives Food fortification programs and food companies in low-income settings, such as in the case of Mexico, lack the ability to monitor the micronutrients added to staples entering local markets. The purpose of the present work is to validate a user-friendly sampling kit and quantify the final error parameters of a paper-based, smartphone-assisted sensor (Nu3px) for the determination of iron in corn flours within the context of Mexico's food fortification program. Methods Corn flour samples (n = 45) from local brands (n = 6) were collected from supermarkets, convenience stores, and directly from companies in the States of Querétaro, Cuautitlán, Saltillo, and Cuetzalan, Mexico. Iron content was analyzed using atomic emission spectroscopy (AES) and Nu3px. The final error parameters were quantified via method validation final experiments, i.e., replication and comparison of methods experiments. Qualitative categorization of samples (i.e., accept/reject batch) was applied to evaluate Nu3px's against Mexico's fortification policy (cutoff = 40 μg Fe/g flour). A user-centered design process was applied to develop and evaluate a sampling kit consisting of low-cost measuring utensils. Results Iron content in fortified Mexican corn flours varied widely (23–39%). Nu3px's random error was 12% (replication experiment, n = 5) and its bias was 1.79 ± 9.99 μg Fe/g flour (comparison of methods experiment, n = 45). The true mean difference between Nu3px and AES was zero (p &amp;gt; 0.05) and both methods had similar variance (F = 2.40; P &amp;gt; 0.05). AES and Nu3px classified the iron content above/below the cutoff in the same way (100% match, Χ2 = 16.41, P = 0.01). The affordable and user-friendly sampling kit added some random error, but the mean difference was equal to zero (P &amp;gt; 0.05). Both sampling procedures were correlated (r = 0.952, P = 0.01). Conclusions An affordable, user-friendly, and equipment-free sample preparation kit for corn flour samples showed similar precision to using analytical tools. The sample preparation kit along with the paper-based, smartphone-assisted assay measure iron within the performance parameters required for its application to monitor batch quality in the corn flour fortification program in Mexico. Funding Sources Fulbright Garcia-Robles Fellowship, 2019.

Prevention of birth defects in East Africa: A review of national policies

Close to 8 million children are born annually with a serious birth defect, accounting for 5% of all newborn deaths globally. Many birth defects are associated with folic acid insufficiency, non-communicable diseases (NCDs), teenage or advanced age pregnancies, short birth intervals, and exposure to harmful substances. The majority of countries with the highest birth defects prevalence are in Africa, and the East African Community has made important commitments to improving reproductive, child, and adolescent health and nutrition. The aim of this review was to identify the advances and gaps in national policies addressing birth defect risk factors in the East African Community (Burundi, Kenya, Rwanda, Tanzania, and Uganda) in order to inform additional actions. National laws, regulations and policies were reviewed from the East African Community countries related to grain fortification and supplementation with folic acid; reducing too-early, unwanted and rapid successive pregnancies; and addressing NCDs and exposure to tobacco. All five countries have adopted a policy of mandatory folic acid fortification of wheat and maize flour. However, only in Kenya and Tanzania, are the folic acid levels in line with international recommendations. And, only Uganda has a policy requiring folic acid supplementation administration in the preconceptional period. The East African Community countries have made efforts to reduce too-early, unwanted and rapid successive pregnancies. All countries have banned child marriage and three of five countries have introduced laws to allow unrestricted access to contraception for adolescents. With regards to promoting prevention and control of NCDs and reducing populations’ exposure, compliance with World Health Organization (WHO) guidelines is limited. Only two countries have developed multi-sectoral policies for NCDs and no countries comply fully with the recommendations of the Framework Convention on Tobacco Control. Much work remains in ensuring that opportunities for prevention of birth defects are fully realized in the East African Community countries. This review revealed that all countries in the East African Community have, to some extent, adopted policies that are conducive to reducing the risk of birth defects in the region, but significant gaps remain in some key areas of either policy development or implementation. Key words: Congenital abnormalities, Folic acid, Family planning services, Child marriage, Non-communicable Diseases

Exposure to the Danish Mandatory Vitamin D Fortification Policy in Prenatal Life and the Risk of Developing Coeliac Disease-The Importance of Season: A Semi Ecological Study.

Few studies have examined the role of maternal diet in relation to development of coeliac disease (CD). In Denmark, cancellation of mandatory vitamin D fortification of margarine in June 1985 provided this opportunity. This study examined if season of birth or prenatal exposure to extra vitamin D from food fortification were associated with developing CD later in life. A strength of this study is the distinctly longer follow-up of patients (30 years). This register-based study has a semi-ecological design. Logistic regression analysis was used to estimate odds ratios and to calculate 95% confidence intervals. The odds ratio for developing CD was 0.81 (95% CI 0.66; 1.00 p = 0.054), comparing those with fetal exposure to mandatory vitamin D fortification policy of margarine to those without after adjusting for gender and season of birth. There was a statistically significant season effect particularly for children born in autumn (OR 1.6 95% CI 1.16; 2.21) and born in summer (OR 1.5 95% CI 1.1; 2.1) when compared to children born in winter. Although this study did not find evidence to support the premise that prenatal exposure to small extra amounts of vitamin D from a mandatory food fortification policy lowered risk of developing CD, the small number of CD cases and observed association between season of birth and CD suggest that environmental exposure ought to be further explored.

Plasma concentrations of vitamin B12 and folate and global cognitive function in an older population: cross-sectional findings from The Irish Longitudinal Study on Ageing (TILDA).

The uncertainty surrounding high intakes of folic acid and associations with cognitive decline in older adults with low vitamin B12 status has been an obstacle to mandatory folic acid fortification for many years. We estimated the prevalence of combinations of low/normal/high vitamin B12 and folate status and compared associations with global cognitive function using two approaches, of individuals in a population-based study of those aged ≥50 years in the Republic of Ireland. Cross-sectional data from 3781 men and women from Wave 1 of The Irish Longitudinal Study on Ageing were analysed. Global cognitive function was assessed by the Mini Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA). Prevalence estimates for combinations of vitamin B12 (plasma vitamin B12 < or ≥258 pmol/l) and folate (plasma folate ≤ or >45·3 nmol/l) concentrations were generated. Negative binomial regression models were used to investigate the associations of vitamin B12 and folate status with global cognitive function. Of the participants, 1·5 % (n 51) had low vitamin B12 (<258 pmol/l) and high folate (>45·3 nmol/l) status. Global cognitive performance was not significantly reduced in these individuals when compared with those with normal status for both B-vitamins (n 2433). Those with normal vitamin B12/high folate status (7·6 %) had better cognitive performance (MMSE: incidence rate ratio (IRR) 0·82, 95 % CI 0·68, 0·99; P = 0·043, MoCA: IRR 0·89, 95 % CI 0·80, 0·99; P = 0·025). We demonstrated that high folate status was not associated with lower cognitive scores in older adults with low vitamin B12 status. These findings provide important safety information that could guide fortification policy recommendations in Europe.

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.

Folate content of gluten-free food purchases and dietary intake are low in children with coeliac disease

The lack of mandated folate enrichment of gluten-free (GF) grains in Canada has been suspected to contribute to suboptimal folate intake among children suffering from Celiac disease (CD). Children with CD on the gluten-free diet (GFD) face nutrient imbalances (higher fat/sugar, lower folate) from processed GF foods. The study objective examined folate intake in children with CD and folate content of household food purchases. Households collected food receipts for 30 days to assess folate content. Folate-rich foods were defined as ≥60 µg dietary folate equivalent (DFE)/100g. Two 24-hour recalls assessed children’s intake. Households (n = 73) purchased >17,000 food items. Median child age was 10.5 y (IQR: 8.4–14.1). GF folate-rich foods represented <15% of all household food purchases and 69% of children had low folate intakes. Folate-rich foods consumed included legumes/GF-breakfast cereals. These represented 5% of GF-food purchases/intake. Few were fortified with folate. Findings highlight the need for mandated GF folate food fortification policy.

Vitamin D Status Increases During Pregnancy and in Response to Vitamin D Supplementation in Rural Gambian Women

Background:Vitamin D is important to maternal, fetal, and infant health, but quality data on vitamin D status in lowand middle-income countries and response to cholecalciferol supplementation in pregnancy are sparse. Objectives:We characterized vitamin D status and vitamin D metabolite change across pregnancy and in response to cholecalciferol supplementation in rural Gambia. Methods:This study was a secondary analysis of samples collected in a 4-arm trial of maternal nutritional supplementation [iron folic acid (FeFol); multiple micronutrients (MMN); protein energy (PE) as lipid-based supplement; PE + MMN]; MMN included 10 µg/d cholecalciferol. Plasma 25-hydroxycholecalciferol [25(OH)D3], 24,25-dihydroxycholecalciferol [24,25(OH)2D3], and C3-epimer-25-hydroxycholecalciferol [3-epi-25(OH)D3] were measured by LC-MS/MS in 863 women [aged 30 ± 7 y (mean ± SD)] in early pregnancy (presupplementation) and late pregnancy, (gestational age 14 ± 3 and 30 ± 1 wk). Changes in 25(OH)D3and vitamin D metabolite concentrations and associations with pregnancy stage and maternal age and anthropometry were tested. Results:Early pregnancy 25(OH)D3concentration was 70 ± 15 nmol/L and increased according to pregnancy stage (82 ± 18 and 87 ± 17 nmol/L in the FeFol and PE-arms) and to cholecalciferol supplementation (95 ± 19 and 90 ± 20 nmol/L in the MMN and PE + MMN-arms) P < 0.0001). There was no difference between supplemented groups. Early pregnancy 25(OH)D3was positively associated with maternal age and gestational age. Change in 25(OH)D3was negatively associated with late pregnancy, but not early pregnancy, triceps skinfold thickness. The pattern of change of 24,25(OH)2D3mirrored that of 25(OH)D3and appeared to flatten as pregnancy progressed, whereas 3-epi-25(OH)D3concentration increased across pregnancy. Conclusions:This study provides important data on the vitamin D status of a large cohort of healthy pregnant women in rural Africa. Without supplementation, vitamin D status increased during pregnancy, demonstrating that pregnancy stage should be considered when assessing vitamin D status. Nutritionally relevant cholecalciferol supplementation further increased vitamin D status. These data are relevant to the development of fortification and supplementation policies in pregnant women in West Africa.

Vitamin D status and current policies to achieve adequate vitamin D intake in the Nordic countries

Aims: Nordic countries share fairly similar food culture and geographical location as well as common nutrition recommendations. The aim of this paper was to review the latest data on vitamin D status and intake and to describe the national supplementation and food fortification policies to achieve adequate vitamin D intake in the Nordic countries. Methods: The data are based on results derived from a literature search presented in a workshop held in Helsinki in November 2018 and completed by recent studies. Results: Vitamin D policies and the implementation of the recommendations differ among the Nordic countries. Vitamin D fortification policies can be mandatory or voluntary and widespread, moderate or non-existent. Vitamin D supplementation recommendations differ, ranging from all age groups being advised to take supplements to only infants. In the general adult population of the Nordic countries, vitamin D status and intake are better than in the risk groups that are not consuming vitamin D supplements or foods containing vitamin D. Non-Western immigrant populations in all Nordic countries share the problem of vitamin D insufficiency and deficiency. Conclusions: Despite the common nutrition recommendations, there are differences between the Nordic countries in the implementation of the recommendations and policies to achieve adequate vitamin D intake and status. There is a need for wider Nordic collaboration studies as well as strategies to improve vitamin D status, especially in risk groups.

Vitamin D Status in Infants during the First 9 Months of Age and its Effect on Growth and Other Biochemical Markers: A Prospective Cohort Study.

Background:Despite food fortification policies in many countries and recommendations for Vitamin D supplementation of at-risk groups, Vitamin D deficiency (VDD) and infantile rickets remain major public health challenges in many developed and developing countries.Materials and Methods:Ninety-six participants at birth were enrolled and followed up until 9 months of age. Serum 25OHD was estimated in cord blood at birth and at 14 ± 1 weeks of life. Seventy-seven participants were followed up at 9 months for estimation of serum 25OHD, parathyroid hormone (PTH), alkaline phosphatase (ALP), calcium, and phosphorus. VDD was defined as serum 25OHD <15 ng/mL as per USIOM guidelines.Results:Serum 25OHD levels at 9 months of age (15.78 ± 8.97 ng/mL) were significantly increased in comparison to the level of 3 months of age (14.04 ± 7.10 ng/mL) and at birth (8.94 ± 2.24 ng/mL). At birth, all the participants (77) were deficient in 25OHD levels. It was found that 16/94 (17%) and 19/77 (24.7%) participants at 3 and 9 months of age, respectively, became Vitamin D sufficient without any Vitamin D supplementation. There was a significant inverse correlation between serum 25OHD and PTH concentration (r = −0.522, P < 0.001), serum 25OHD and ALP (r = −0.501, P < 0.001). It was found that reduction in serum Vitamin D level to <10.25 ng/mL results in a surge of serum PTH.Conclusion:VDD is common from birth to 9 months of age but incidence decreases spontaneously even without supplementation. Furthermore, a large number of babies may be falsely labeled as Vitamin D deficient with currently followed cutoffs. Hence a new cutoff for VDD needs to be established for neonates and infants.

Fortification of bakery and corn masa–based foods in Mexico and dietary intake of folic acid and folate in Mexican national survey data

In Mexico, wheat and corn flour fortification with folic acid (FA) was implemented in 2001 and mandated in 2008, but without direct enforcement. Current Mexican nutrient-content tables do not account for FA contained in bakery bread and corn masa-based foods, which are dietary staples in Mexico. The objective of this study was to examine the impact of FA fortification of dietary staples on the proportion of the population consuming below the Estimated Average Requirement (EAR) for folate or above the Tolerable Upper Intake Level (UL) for FA. We measured FA and folate content in dietary staples (bakery bread and tortillas) using microbial assays and MS, and we recalculated FA intake from 24-h recall dietary intake data collected in the 2012 Mexican National Health and Nutrition Survey (Encuesta Nacional de Salud y Nutrición) utilizing estimates from our food measurements, using nutrient concentrations from tortillas to approximate nutrient content of other corn masa-derived foods. The revised FA intake estimates were used to examine population-level intake of FA and dietary folate equivalent (DFE) accounting for geographic differences in FA content with statistical models. FA content in dietary staples was variable, whereas use of FA-fortified flour in corn masa tortillas increased with population size in place of residence. Accounting for dietary staples' FA fortification increased population estimates for FA and DFE intake, resulting in a lower proportion with intake below the EAR and a higher proportion with intake above the UL. Despite accounting for FA-fortified staple foods, 9-33% of women of childbearing age still have intake below the EAR, whereas up to 12% of younger children have intake above the UL. Unregulated FA fortification of dietary staples leads to unpredictable total folate intake without adequately impacting the intended target. Our findings suggest that monitoring, evaluation, and enforcement of mandatory fortification policies are needed. Without these, alternate strategies may be needed in order to reach women of childbearing age while avoiding overexposing children.

Awareness and factors associated with reported intake of folic acid-fortified flour among women of reproductive age in Ifakara, Morogoro region, Tanzania: a cross-sectional study

BackgroundFolic acid fortification of staple foods has been in place in many countries for over two decades. Studies have shown that folic acid fortification can significantly reduce incidence of neural tube defects. Tanzania adopted a mandatory fortification policy for commercially-produced wheat and maize flour in 2011. We determined factors influencing intake of folic acid-fortified flour among women of reproductive age (WRA).MethodsWe conducted a cross-sectional study among WRA during March–April 2017 in Ifakara Town Council, Morogoro region. Multistage cluster sampling was used to select study participants. We used a questionnaire to capture information on demographics, awareness of folic acid, awareness of existence of folic acid fortified flour in community and intake of folic acid fortified flour. Intake was defined as reported consumption of folic acid fortified flour products at least once within 7 days before interview. Univariate, bivariate, and multivariable logistic analyses were done to evaluate factors associated with intake of folic acid fortified flour.ResultsThe median age of the 698 participating WRA was 30 years (range: 18–49). Awareness of folic acid and folic acid fortified flour was 6.9% (95% CI: 5.2–9.0%) and 7.5% (95% CI: 5.7–9.6%), respectively. Consumption of folic acid fortified flour was 63.3% (95% CI: 59.7–66.8%). Independent factors associated with intake included being employed (aOR = 1.91; 95% CI: 1.19–3.06), having no children (nulliparity) (aOR = 2.59; 95% CI: 1.36–4.95) or having 1–4 children (aOR = 1.98; 95% CI: 1.17–3.33) (vs. 5 or more children), and folic acid awareness (aOR = 2.53; 95% CI: 1.30–4.92).ConclusionFolic acid fortified flour was used by most respondents in our study despite low awareness of existence of folic acid fortified flour in the community. Being employed, having fewer than five children, and folic acid awareness were independent factors associated with intake. We recommend scaling up of mandatory flour fortification program and doing further studies on blood folate level among women of reproductive age in Ifakara to assess fortification program effectiveness.

Development of a Paper-Based Sensor Compatible with a Mobile Phone for the Detection of Common Iron Formulas Used in Fortified Foods within Resource-Limited Settings.

A lack of quality control tools limits the enforcement of fortification policies. In alignment with the World Health Organization’s ASSURED criteria (affordable, sensitive, specific, user-friendly, rapid and robust, equipment-free, and deliverable), a paper-based assay that interfaces with a smartphone application for the quantification of iron fortificants is presented. The assay is based on the Ferrozine colorimetric method. The reaction started after deposition of the 5 µL aqueous sample and drying. After developing color, pixel intensity values were obtained using a smartphone camera and image processing software or a mobile application, Nu3px. From these values, the actual iron concentration from ferrous sulfate and ferrous fumarate was calculated. The limits of detection, quantification, linearity, range, and errors (systematic and random) were ascertained. The paper-based values from real samples (wheat flour, nixtamalized corn flour, and infant formula) were compared against atomic emission spectroscopy. The comparison of several concentrations of atomic iron between the spectrophotometric and paper-based assays showed a strong positive linear correlation (y = 47.01x + 126.18; R2 = 0.9932). The dynamic range (5.0–100 µg/mL) and limit of detection (3.691 µg/mL) of the paper-based assay are relevant for fortified food matrices. Random and systematic errors were 15.9% and + 8.65 µg/g food, respectively. The concept can be applied to limited-resource settings to measure iron in fortified foods.

Daily Iron Requirements in Healthy Indian Children and Adolescents

This study aimed to define the estimated average requirement and the recommended dietary allowance of iron for Indian children and adolescents. The Estimated average requirement was derived for children aged 1-17y, from the mean bioavailability-adjusted daily physiological iron requirement, which in turn was estimated using a factorial method. This consisted of mean daily iron losses from the body and additional iron required for tissue growth and storage, while also defining the variance of each factor to derive the Recommended dietary allowance. Results: The estimated average requirement of iron for children ranged from 5.6 to 11.0 mg/d in children aged 1-9y. For adolescents aged 10-17y, these ranged from 10.8 to 18.4 mg/d and 15.4 to 18.5 mg/d for adolescent boys and girls, respectively. New estimates of estimated average requirement for iron in Indian children are presented, and same may be used to inform iron supplementation and food fortification policies.