Search

Since the late 1990s, the International Potato Center has promoted orange-fleshed sweet potato (OFSP) cultivars in Mozambique as a healthy food, emphasizing its capacity to reduce the prevalence of vitamin A deficiency among mothers and young children. This article seeks to reveal why consumers in Maputo, the capital city of Mozambique, adopt or reject OFSP looking at the role of food systems and consumer characteristics in access and acceptance of healthy food and at the positioning of OFSP on the market in terms of lifestyle and need satisfaction. The results of 255 street interviews confirm that OFSP is widely known. Information reaches people mainly via informal channels (relatives and retailers). Nonadoption is the result of the positioning of OFSP as food for young children and sick people. The OFSP appeals most to the hedonistic and conservative lifestyle segments. Adoption is associated with the perception of OFSP as a source of vitamins that builds up muscles and improves physical appearance and self-fulfillment. While women are typically responsible for domestic tasks, male adopters emphasize the role of OFSP in family health and well-being more than female adopters. This first attempt to understand the marketing of healthy food in Mozambique exposes many similarities between the urban consumers in Maputo and those in developed countries. The results indicate that future marketing should exploit informal channels such as vendors and emphasize its nutritious value for all consumers instead of focusing on mothers and young children.

Palestine refugees comprise the largest refugee population in the world, most of whom are encamped in Middle Eastern countries. In the Gaza Strip, where ∼1.4 million Palestinians reside, there are high prevalences of anemia and multiple micronutrient deficiencies (MNDs), including those of iron, zinc, vitamins A, B12, D, and E, ranging from 11.4% to 84.7% among pregnant women and 2.9% to 70.9% among preschool children. Dietary diversification and adequate food fortification are framed in policies but remain aspirational goals. Alternative, effective, targeted preventive approaches include, for women, replacement of antenatal iron-folic acid with multiple micronutrient supplementation, and for young children, point-of-use multiple micronutrient powder fortification to prevent anemia, both of which can reduce other MNDs and may bring additional health benefits. These interventions coupled with monitoring of dietary intakes, periodic assessment of MNDs, and implementation research to improve existing nutrition interventions are warranted to protect the health of the Middle East Palestinian diaspora.

Solomon Islands (SI) mandated wheat flour fortification in 2010. Rice is a key staple food in SI, and its fortification may provide an opportunity to deliver additional micronutrients to the population.To determine whether fortified rice (proposed) and fortified wheat flour potentially benefit women of reproductive age (WRA).We analyzed data from the 2012-2013 Household Income and Expenditure Survey to quantify food purchases, which served as a proxy for food consumption. We accounted for varied household composition by using adult male equivalent (AME) adjustments.Among 4478 households, 95.6% purchased rice and 86.6% purchased at least 1 food containing fortified wheat flour in the previous 14 days. Median apparent intake of rice among WRA was 205 g/d/AME. If fortified according to proposed standards, this apparent intake could result in the consumption of 12.3 mg iron/d, fulfilling 44% of the estimated average requirement (EAR), and 226 µg folic acid/d, satisfying 57% of World Health Organization's recommended intake of 400 µg/d. Overall, apparent rice consumption could fulfill 113%, 114%, and 131% of the EAR for WRA for zinc, thiamin, and niacin, respectively. Fortified wheat flour was consumed in much lower quantities, with an estimated apparent median intake of 22 g/d/AME among WRA and 78 g/d/AME among women in urban populations.The potential benefit of fortified wheat flour in SI is likely limited to urban populations. Apparent consumption of fortified rice in SI could contribute considerably to daily intake of iron, B vitamins including folic acid, and zinc among WRA.

Background: Despite several interventions, India has made little progress in reducing hidden hunger, micronutrient malnutrition. Food fortification of staple foods could be useful in addressing the above problem. Nonetheless, it may lead to an increase in economic stress among people by increasing inflation and monthly budget expenditure. Objective: The prime objective was to see whether or not mandatory food fortification will lead to an increase in inflation and the family’s budget expenditure. Methods: The study was based on secondary data. Decomposition approach has been used—inflation was decomposed into contributions of each commodity and which was further divided into base, weight, and inflation effects. To estimate the impact of mandatory food fortification on the family’s budget expenditure, monthly per capita expenditure has been assessed by considering both the situations—with and without fortification. Results: Results suggest that mandatory food fortification has a very negligible effect on inflation, suggesting no rise in inflation due to mandatory food fortification in India. Also, the study suggests a minimal increase in monthly per capita expenditure in both rural and urban sectors of India. Conclusions: Though adopting mandatory food fortification in India will not have an impact on inflation, there would be 2 major challenges: high dependency on food items processed locally and unawareness of benefits of fortified food items. Therefore, the government can first start food fortification of staple food with safety nets programs like NFSA, focusing on the most vulnerable groups of the society, and then scale up at a large scale.

Background: Maize is the major food staple in East and Southern Africa, where food-processing industries are emerging fast. New low-cost extrusion cookers allow small enterprises to enter the market for processed cereals, including instant, fortified, and flavored products. Objective: Assess consumers’ interest and preferences for the new products. Methods: Consumers (n = 220) in Eldoret, Kenya, were invited to evaluate 4 new cereal products: (1) sifted maize flour mixed with sorghum, (2) instant sifted mixed flour, (3) instant whole flour, and (4) instant whole flour fortified with natural ingredients and to compare them to conventional sifted maize flour, using 2 preparations: stiff porridge ( ugali) and soft porridge ( uji). These were followed by economic experiments to estimate consumers’ willingness to pay (WTP) for the new products and traits. Results: For ugali, consumers preferred conventional sifted maize flour, while for uji, they appreciated the new products, especially sifted mixed flour (with sorghum) and instant whole mixed flour. Fortification with food-to-food sources was not appreciated, especially for ugali. Comparing WTP for the traits with their production cost showed that mixed, whole, and instant flours were economical, but not fortification. Maize/sorghum mixtures realized a benefit of 24% over conventional maize flour, whole meal 11%, and instant mixtures 5%. Conclusions: There is a potential market for improved cereal products in Kenya, but more for uji than for ugali, especially with instant, mixed, and whole flour. Acceptable and affordable products, fortified with other foods that are locally available, however, still need to be developed, especially for ugali.

Background: Intake of micronutrient-rich foods among children aged 6 to 23 months in Nairobi is low. Objective: This study aimed to assess existing coverage and utilization of micronutrient powders (MNPs), fortified staples, and iodized salt among children aged 6 to 23 months prior to implementation of an MNP program. Methods: A cross-sectional survey among caregivers of children aged 6 to 23 months (n = 618) was implemented in 7 neighborhoods within Nairobi County, representing the implementation area of the new MNP program. Results: Results for MNP coverage and utilization showed 28.5% of all caregivers were aware of MNP, 18.5% had ever received MNP for their child, and 10.8% had fed MNP to their child in the previous 7 days. Effective coverage (ie, the child had been given the MNP at least 3 times in the previous 7 days) was 5.8%. Effective coverage of infants and young children with poor feeding practices was significantly lower as compared to those with non-poor feeding practices (coverage ratio, 0.34; confidence interval, 0.12-0.70). Most households purchased iodized salt (96.9%), fortified oil (61.0%), and fortified maize flour (93.9%). An estimated 23.9% of vitamin A requirements of children (6-23 months) were provided from fortified oil and 50.7% of iron from fortified maize flour. Most households consumed processed milk (81%). Conclusion: Coverage of MNPs in the surveyed neighborhoods was low. Coverage of fortified salt, oil, and maize flour was high and provided significant amount of micronutrients to children. Processed milk has potential as a vehicle for food fortification.

Background: There are few effectiveness evaluations of food fortification programs, and little is known about what makes programs successful. Objective: We examined 3 food fortification programs in Latin America to identify common features that might explain their success and to draw lessons for program design and implementation everywhere: The vitamin A fortification of sugar in Guatemala with impact on vitamin A status of the population, the fortification of a basket of foods with iron and other micronutrients in Costa Rica with impact on iron status and anemia in women and children, and the fortification of wheat flour with folic acid in Chile, which reduced the incidence of neural tube defects. Methods: We identified pertinent literature about these preselected programs and asked regional experts for any additional information. We also conducted structured interviews of key informants to provide historical and contextual information. Results: Institutional research capacity and champions of fortification are features of successful programs in Latin America. We also found that private/public partnerships (industry, government, academia, and civil society) might be key for sustainability. To achieve impact, program managers need to use fortification vehicles that are consumed by the nutritionally vulnerable and to add bioavailable fortificants at adequate content levels in order to fill dietary gaps and reduce micronutrient deficiencies. Adequate monitoring and quality control are essential. Conclusions: For future programs, we recommend that the evaluation be specified up-front, including a baseline/end line and data collection along the program impact pathway to inform needed improvements and to strengthen causal inferences.

Background: In 2005, more than 90% of Vietnamese households were using adequately iodized salt, and urinary iodine concentration among women of reproductive age was in the optimal range. However, household coverage declined thereafter to 45% in 2011, and urinary iodine concentration levels indicated inadequate iodine intake. Objective: To review the strengths and weaknesses of the Vietnamese universal salt iodization program from its inception to the current day and to discuss why achievements made by 2005 were not sustained. Methods: Qualitative review of program documents and semistructured interviews with national stakeholders. Results: National legislation for mandatory salt iodization was revoked in 2005, and the political importance of the program was downgraded with consequential effects on budget, staff, and authority. Conclusions: The Vietnamese salt iodization program, as it was initially designed and implemented, was unsustainable, as salt iodization was not practiced as an industry norm but as a government-funded activity. An effective and sustainable salt iodization program needs to be reestablished for the long-term elimination of iodine deficiency, building upon lessons learned from the past and programs in neighboring countries. The new program will need to include mandatory legislation, including salt for food processing; industry responsibility for the cost of fortificant; government commitment for enforcement through routine food control systems and monitoring of iodine status through existing health/nutrition assessments; and intersectoral collaboration and management of the program. Many of the lessons would apply equally to universal salt iodization programs in other countries and indeed to food fortification programs in general.

Background: A national mandatory food fortification program, fortifying wheat flour and maize meal with various micronutrients, was introduced in South Africa in 2003 to address micronutrient deficiencies. Objective: This study aimed to determine vitamin A, iron, and zinc content of raw maize meal and wheat flour bread sampled at household level from 2 urban and 2 rural areas in South Africa and to compare with the regulatory minimum requirements. Methods: Maize meal (250 g) and/or supermarket/local shop bread (3 inner slices) were collected from 50 randomly selected households from each study area. Maize meal samples were reduced to 10 composite samples per area. Bread samples were composited similarly; 1 composite sample consisted of 15 intact slices. Overall, 8 composite samples were obtained for both brown and white bread. The Southern African Grain Laboratory analyzed the samples for vitamin A, iron, and zinc. Results: Mean content of maize meal (100 g) represented ratios of 0.56 to 0.98 of the minimum fortification requirement for vitamin A, 0.76 to 1.08 for iron, and 0.89 to 1.00 for zinc; brown bread (100 g) represented ratios of 0.57, 1.97, and 1.67 of the minimum requirement for vitamin A, iron, and zinc, respectively, and white bread (100 g) represented ratios of 0.89, 2.22, and 2.07 for vitamin A, iron, and zinc, respectively. Conclusion: The variation in vitamin A, iron, and zinc content in maize meal and the higher than required iron and zinc content in wheat bread needs to be investigated in further studies.

Background: Household Consumption and Expenditures Surveys (HCES) are potential sources of data on dietary patterns for planning fortification programs, but they rarely have been compared with individual-level dietary assessment methods. Objective: To compare apparent consumption of fortifiable foods estimated from the Third Cameroon Household Survey (ECAM3) with the results of a national dietary survey using food frequency questionnaire (FFQ) and 24-hour recall (24HR) methods among women aged 15 to 49 years and children aged 12 to 59 months. Methods: We estimated coverage and frequency of consumption in the previous week (ECAM3 and FFQ) and coverage and amount consumed on the previous day (ECAM3 and 24HR) of refined vegetable oil, wheat flour, sugar, and bouillon cubes. Results: Coverage in the past week as measured by the ECAM3 and FFQ, respectively, was 64% vs. 54% for oil, 60% vs. 92% for flour, 69% vs. 78% for sugar, and 85% vs. 96% for bouillon cubes. The different methods identified similar patterns of coverage among subgroups for oil, but patterns for other foods were variable. Frequency of consumption and previous-day coverage were lower with the ECAM3 than with the FFQ and 24HR, likely reflecting infrequent acquisition relative to intake. For women, the mean amounts consumed on the previous day (among consumers) were 43 vs. 29 g of oil, 71 vs. 83 g of flour, 42 vs. 32 g of sugar, and 5.0 vs. 2.4 g of bouillon cubes (ECAM and 24HR, respectively). Conclusions: HCES provide useful information on patterns of food access but inadequate information on individual consumption amounts to estimate appropriate food fortification levels.

Background: Industrial food fortification is a major strategy to improve dietary micronutrient intakes and prevent deficiencies. Zambia introduced mandatory sugar fortification with vitamin A, at a target of 10 mg/kg, in 1998. Representative surveys conducted since that time do not support marked improvement in vitamin A status. Objective: To describe vitamin A concentrations in retail sugar, as well as vendor practices, perceptions of fortified foods, and sugar use practices. Methods: We conducted a census of sugar vendors in one Zambian community, capturing information on vendors, available brands and packaging options, and storage conditions. We purchased all brands and package types of sugar available at each vendor. In a 15% subsample, we conducted semi-structured interviews with vendor–consumer pairs. We tested 50% of sugar samples at random for vitamin A using an iCheck portable fluorimeter. Results: The distribution of vitamin A in sugar in market samples was highly skewed, with a median of 3.1 mg/kg (25th-75th percentiles: 1.8-5.5) and a range from 0.2 to 29.9 mg/kg. Only 11.3% of samples met the 10 mg/kg statutory requirement. Sugar was primarily repackaged and sold in small quantities, with rapid turnover of stocks. Perceptions of fortification by vendors and consumers were generally positive. Conclusions: Vitamin A in fortified sugar fell well below statutory requirements. Our data point to challenges at regional depot and/or poor adherence to fortification standards at the factory level. A renewed commitment to monitoring and enforcement will be required for Zambia to benefit from a food fortification strategy.

Background Food fortification is a cost-effective, powerful, and sustainable strategy to combat micronutrient deficiency, with the potential to reach large sections of the population with minimal cost and effort. However, the implementation of food fortification on a systematic and large scale, for instance in national programs, has often been challenging. Objective This paper takes a closer look at food fortification efforts and legislation mechanisms in Vietnam and Indonesia in order to determine specific factors and components in the legal framework that are crucial to the success of fortification programs. Methods Fortification efforts in Indonesia and Vietnam are evaluated using published data as well as unpublished data from detailed evaluation reports, and compared with respect to the specific circumstances, constraints, objectives and results in each country. Results The legal framework is a crucial factor for the success of food fortification programs, as it shapes to a large extent the implementation of food fortification. The legal framework is instrumental to ensure the quality, safety, availability, cost-effectiveness, and sustainability of food fortification. In the first place, the legal framework should specify the fortificants and fortification levels, as well as the food vehicles and the fortification procedures. In addition, it should ensure the commitment of policy makers and producers to fortification, regulate the costing, describe and ensure information and communication such as product labeling, integrate social marketing into the implementation, and provide the means to monitor and enforce fortification. A clear public health objective, together with careful consideration of the choices and restrictions dictated by the specific national environments, will help to develop legal frameworks that optimize the potential success of food fortification strategies. Conclusions The lessons from these experiences show that a mandatory approach to fortification, with costing, monitoring and enforcement, and social marketing clearly defined and well embedded in the legal framework and in the implementation structures, is the best foundation for an effective, sustainable, and feasible food fortification program.

Background:Two billion people worldwide have micronutrient deficiencies. Food fortification is a proven intervention to increase essential micronutrient availability in diets without requiring consumer behavioral change. Fortification of rice has high potential reach; however, cost, technology, market, and cultural constraints have prevented its wider adoption.Objective:From 2010 to 2014, PATH and Global Alliance for Improved Nutrition implemented a pilot project in Brazil testing a model to scale up rice fortification through commercial channels. The project focused on 5 areas: (1) building fortified rice kernel production capacity; (2) supply chain development; (3) distribution channel and market development; (4) demand generation; and (5) advocacy and knowledge dissemination.Methods:Primary data were collected in 2 rounds of quantitative research 6 months apart and conducted in 2 regions in Brazil. Secondary data were sourced from published literature, socioeconomic and demographic data, and sales figures from the project’s rice miller partner. Postmortem analysis was conducted by the project team with input from external sources.Results:Although the project successfully launched a fortified rice product and a category brand platform, it was unsuccessful in reaching meaningful scale. Market and industry dynamics affected producers’ willingness to launch new fortified products. Consumers’ strong attachment to rice combined with a weak understanding of micronutrient malnutrition hampered demand creation efforts.Conclusion:This project showed that a purely commercial approach is insufficient for sustainable scale-up of fortified rice to achieve public health goals in a 3- to 5-year period.

Food fortified with folic acid has been available for consumption in North America for over a decade. This strategy has led to an increase in folate levels in the general population and, more importantly, a significant decrease in the incidence of neural tube defects. However, this increase in folate intake has been associated with a greater risk of cancer disease. Many African countries are now embracing this concept; however, because folate promotes malaria parasite division, as it does in cancer cells, there is a possibility of malaria exacerbation if folate intake is increased. A precedent for such a concern is the now compelling evidence showing that an increase in iron intake can lead to a higher malaria risk; as a result, mass administration of iron in malaria-endemic areas is not recommended. In this article, we review work on the effect of folate on malaria parasites. Although this topic has received little research attention, the available data suggest that the increase in folate concentration could be associated with an increase in malaria infection. Thus, the introduction of food fortification with folic acid in malaria-endemic areas should be attended by precautionary programs to monitor the risk of malaria.

Background Food fortification began in Ghana in 1996 when legislation was passed to enforce the iodization of salt. This paper describes the development of the Ghanaian fortification program and identifies lessons learned in implementing fortification initiatives (universal salt iodization, fortification of vegetable oil and wheat flour) from 1996 to date. Objective This paper identifies achievements, challenges, and lessons learned in implementing large scale food fortification in Ghana. Methodology Primary data was collected through interviews with key members of the National Food Fortification Alliance (NFFA), implementation staff of the Food Fortification Project, and staff of GAIN. Secondary data was collected through desk review of documentation from the project offices of the National Food Fortification Project and the National Secretariat for the Implementation of the National Salt Iodization in Ghana. Results Reduction of the prevalence of goiter has been observed, and coverage of households with adequately iodized salt increased between 1996 and 2006. Two models were designed to increase production of adequately iodized salt: one to procure and distribute potassium iodate (KIO3) locally, and the second, the salt bank cooperative (SBC) model, specifically designed for small-scale artisanal salt farmers. This resulted in the establishment of a centralized potassium iodate procurement and distribution system, tailored to local needs and ensuring competitive and stable prices. The SBC model allowed for nearly 157 MT of adequately iodized salt to be produced in 2011 in a region where adequately iodized salt was initially not available. For vegetable oil fortification, implementing quantitative analysis methods for accurate control of added fortificant proved challenging but was overcome with the use of a rapid test device, confirming that 95% of vegetable oil is adequately fortified in Ghana. However, appropriate compliance with national standards on wheat flour continues to pose challenges due to adverse sensory effects, which have led producers to reduce the dosage of premix in wheat flour. Conclusions Challenges to access to premix experienced by small producers can be overcome with a central procurement model in which the distributor leverages the overall volume by tendering for a consolidated order. The SBC model has the potential to be expanded and to considerably increase the coverage of the population consuming iodized salt in Ghana. Successful implementation of the cost-effective iCheck CHROMA rapid test device should be replicated in other countries where quality control of fortified vegetable oil is a challenge, and extended to additional food vehicles, such as wheat flour and salt. Only a reduced impact on iron deficiency in Ghana can be expected, given the low level of fortificant added to the wheat flour. An integrated approach, with complementary programs including additional iron-fortified food vehicles, should be explored to maximize health impact.

The Global Alliance for Improved Nutrition (GAIN) was established in 2002 with a mandate to galvanize efforts by the public and private sectors to end malnutrition. GAIN launched its first large-scale fortification program in 2003, and in less than a decade has scaled its operations to reach more than 600 million people with nutritionally enhanced food. GAIN has evolved considerably as an organization, expanding beyond large-scale food fortification into new program areas, focusing on maternal, infant, and young child nutrition and improvements in agricultural practices to enhance nutrition. This paper describes GAIN's evolution from a large-scale food fortification program focus to a broader nutrition program portfolio directed toward improving access and affordability of nutritious foods for the poor. As GAIN enters its second decade, it continues to respond to the challenges of a changing nutrition landscape by introducing new programs and novel partnerships and by refining its innovative program delivery models.

Background In sub-Saharan Africa, more than 42% of children are at risk for vitamin A deficiency, and control of vitamin A deficiency will prevent more than 600,000 child deaths annually. In the West African Economic and Monetary Union (UEMOA), an estimated 54.3% of preschool-age children are vitamin A deficient and 13% of pregnant women have night blindness. Objective To project the achievements of this West African coalition. Methods This article documents the achievements, challenges, and lessons learned associated with the development of a public—private partnership to fortify vegetable oil in West Africa through project reports and industry assessments. Results National-level food consumption surveys identified cooking oil as a key vehicle for vitamin A. Stakeholders therefore advocated for the production of fortified vegetable oil at large scale, supported industrial assessments, and reinforced the capacity of cooking oil industries to implement vitamin A fortification through effective coordination of public and private partnerships tied with standards, regulations, and social marketing. Strong alliances for food fortification were established at the regional and national levels. Stakeholders also developed policies, adopted directives, built capacity, implemented social marketing, and monitored quality enforcement systems to sustain fortification for maximum public health impact. The synergy created resulted from the unique and complementary core competencies of all the partners under effective coordination. The initiative began with the 8 UEMOA member countries and now includes all 15 countries of the Economic Community of West African States (ECOWAS), plus Cameroon, Tanzania, and Mozambique, forming a sub-Saharan Africa-wide initiative on food fortification. All members of the Professional Association of Cooking Oil Industries of the West African Economic and Monetary Union (AIFO-UEMOA) now fortify edible oil with vitamin A. Through multisector cooperation, an estimated 70% of the population has access to vitamin A–fortified edible oil in participating countries. Conclusions Sustainable fortification of cooking oil is now a reality in all UEMOA countries.

Vitamin and mineral deficiencies are ranked among the top causes of poor health and disability in the world. These deficiencies damage developing brains, impair learning ability, increase susceptibility to infections, and reduce the work productivity of nations. Food fortification is a sustainable, cost-effective approach to reducing vitamin and mineral deficiency. As the staple food for an estimated 3 billion people, rice has the potential to fill an obvious gap in current fortification programs. In recent years, new technologies have produced fortified rice kernels that are efficacious in reducing vitamin and mineral deficiency. There are opportunities to fortify a significant share of rice that comes from large mills supplying centralized markets and national welfare programs in major rice-growing countries. The rice export markets, which handle 30 million MT of rice annually, also present a key fortification opportunity. The cost of fortifying rice is only 1.5% to 3% of the current retail price of rice. Countries that mandate rice fortification have the strongest evidence for achieving wide coverage and impact. The Rice Fortification Resource Group (RiFoRG), a global network of public and private partners that offers technical and advocacy support for rice fortification, has a vision of promoting rice fortification worldwide. It has a targeted approach, engaging multisector partners in key countries where the opportunities are greatest and there is receptivity to early adoption of large-scale rice fortification. The challenges are real, the imperative to address them is powerful, and the opportunities to deliver the promise of rice fortification are clear.

Background Fortification of staple foods has been repeatedly recommended as an effective approach to reduce micronutrient deficiencies. With the increased number of fortification projects globally, there is a need to share practical lessons learned relating to their implementation and responses to project-related and external challenges. Objective To document the achievements, challenges, lessons learned, and management responses associated with national fortification projects in Morocco, Uzbekistan, and Vietnam. Methods Independent end-of-project evaluations conducted for each project served as the primary data source and contain the history of, and project activities undertaken for, each fortification project. Other sources, including national policy documents, project reports from the Global Alliance for Improved Nutrition (GAIN) and other stakeholders, industry assessments, and peer-reviewed articles, were used to document the current responses to challenges and future project plans. Results All projects had key achievements related to the development of fortification standards and the procurement of equipment for participating industry partners. Mandatory fortification of wheat flour was a key success in Morocco and Uzbekistan. Ensuring the quality of fortified foods was a common challenge experienced across the projects, as were shifts in consumption patterns and market structures. Adjustments were made to the projects' design to address the challenges faced. Conclusions National fortification projects are dynamic and must be continually modified in response to specific performance issues and broader shifts in market structure and consumption patterns.

Background Micronutrient malnutrition, caused largely by inadequate dietary intake, is a global public health problem that adversely affects health, child growth and development, work capacity, and quality of life. Mass fortification of widely consumed edible products has the potential to increase micronutrient intakes and thus alleviate some nutritional deficiencies. Although individual-level data about food consumption patterns are ideal for informing the design of food fortification programs, they are often unavailable. Household Consumption and Expenditures Surveys (HCES) are nationally representative cross-sectional surveys conducted over a 12-month period every 2 to 5 years, primarily to characterize household expenditures. Objective We describe how expenditure data from HCES can serve as a proxy for household food consumption and thus aid in choosing which foods to fortify and in determining how much of a micronutrient to add to that food. Methods We describe methods of using HCES data to characterize apparent food consumption patterns among different strata within a population. Results There are several limitations of using HCES data to describe apparent food consumption. HCES do not directly capture information about true food intake, but rather describe food expenditures. We assume that purchased foods are not shared with guests, wasted, fed to animals, gifted, or stockpiled for later use. We also assume that foods are allocated within each household based on energy needs. Conclusions Despite the limitations of using HCES data to estimate apparent food consumption, the dearth of individual-level data about food intake renders HCES data useful in designing food fortification programs.

Background The selection of food vehicles and fortification levels in food fortification programs may be made on the assumption of equitable intrahousehold distribution of food. There are concerns that biased intrahousehold distribution of food will make food-based interventions ineffective or unsafe. Objective To review available data documenting intrahousehold energy intake (as a proxy for food distribution) in low- and middle-income countries, and discuss the relevance for food fortification programs. Methods A literature search was done, selecting reports from low- and middle-income countries that included dietary data from adults and children. The references of relevant reports and all citations of relevant reports were scanned. Intrahousehold distribution of dietary energy was compared with individual energy requirements. Results Twenty-eight studies were identified covering 18 countries with as few as 20 and as many as 3,000 households per study. Intrahousehold distribution of food in most countries is relatively equitable, within a 20% margin. Conclusions Within the limits of the available data, and in the absence of contrary data, it is reasonable to assume equitable intrahousehold distribution of food when designing food fortification programs; however, for program evaluation, individual assessment of intake is still needed.

Background Household Consumption and Expenditures Surveys (HCES) are routinely conducted in several countries on nationally representative samples, often on a regular basis. The HCES have been considered as a potential alternative to more expensive surveys of individuals' food intakes for use in nutritional assessment and in planning programs such as food fortification. HCES gather information on household food availability (purchased, produced, or received as gifts) and use over a given period of time, often the past week or month. Objective To discuss the potential usefulness of HCES consumption data for nutritional assessment and planning for populations of households and individuals within the households. Conclusions There are several limitations to the HCES, most notably the difficulty of estimating the intrahousehold allocation of foods and therefore of quantifying the actual food intake of individual household members. Another concern is the lack of information on the variability of consumption over time, making it difficult to estimate the distribution of usual consumption, and thus the prevalence of nutrient inadequacies or excesses. Other potential limitations might be addressed by improvements to the HCES questionnaires, such as including information on foods that are available but not consumed and those that are consumed outside the home. Research is needed to better understand both the strengths and the weaknesses of the HCES data when used to assess and plan intakes at the household and individual levels

Background Information on dietary intake is essential for the assessment, planning, monitoring, and evaluation of nutritional interventions. A number of methods are available, each with unique strengths and weaknesses. Dietary intake records, 24-hour recalls, and Food Frequency Questionnaires (FFQs) determine food consumption and nutrient intakes of populations based on individual assessment; few countries have such data at national or regional levels. Food and Agriculture Organization (FAO) Food Balance Sheets (FBS) and food industry data, available in most countries, permit calculations of per capita food consumption but do not provide data on individual consumption. Household Consumption and Expenditures Surveys (HCES) are available for most countries and provide data that can be used to calculate consumption of fortification vehicles and to estimate additional intakes of micronutrients delivered through them to specific population groups. Objective To introduce the reader to the set of papers included in this Supplement reviewing methods and experience with HCES to inform nutrition, and specifically food fortification programs. Methods The Monitoring, Assessment, and Data (MAD) working group and colleagues critically reviewed experiences in estimating dietary intakes, focusing on the use of secondary analysis of HCES. Results HCES predict coverage of the population that consumes a fortification vehicle and consumed amounts of fortification vehicles. HCES allow comparisons of different population strata and may also approximate micronutrient adequacy, based on nutrient density, at the household level. Conclusions HCES are useful to inform food fortification and other nutrition programs for planning interventions, but further work is necessary. Currently, combined use of traditional dietary surveys is needed for assessment and for program monitoring and evaluation.

Background Macronutrient and micronutrient deficiencies continue to have a detrimental impact in lower-income countries, with significant costs in morbidity, mortality, and productivity. Food is the primary source of the nutrients needed to sustain life, and it is the essential component that links nutrition, agriculture, and ecology in the econutrition framework. Objective To present evidence and analysis of food-based approaches for improving nutritional and health outcomes in lower-income countries. Methods Review of existing literature. Results and conclusions The benefits of food-based approaches may include nutritional improvement, food security, cost-effectiveness, sustainability, and human productivity. Food-based approaches require additional inputs, including nutrition education, gender considerations, and agricultural planning. Although some forms of malnutrition can be addressed via supplements, food-based approaches are optimal to achieve sustainable solutions to multiple nutrient deficiencies.

Background The prevalence of micronutrient deficiencies, in particular those of iron, vitamin A, iodine, and zinc, is unacceptably high, especially among infants, children, and women of childbearing age in developing countries. Effective food-based strategies to combat these public health problems are therefore urgently needed. Objective As only a fraction of dietary iron, zinc, and provitamin A carotenoids is absorbed and utilized, i.e., bioavailable, access to information on micronutrient bioavailability is crucial in the development of food fortification strategies and interventions based on dietary diversification. Methods Review of literature Results and conclusions This overview highlights the usefulness of stable isotope techniques to assess the bioavailability of nonheme iron and provitamin A carotenoids and the importance of generating data on micro-nutrient bioavailability to move the agenda forward.

Background A project for universal salt iodation with potassium iodate and wheat flour fortification with a vitamin-mineral premix was implemented in Azerbaijan, Kazakhstan, Kyrgyzstan, Mongolia, Tajikistan, and Uzbekistan between 2002 and 2007. Objective To determine the potential effectiveness of the food fortification programs in improving the micronutrient status of selected families in a sentinel population in each country. Methods An area was selected in each country in a sentinel population expected to have early access to iodated salt and fortified wheat flour. Within this area, an average of 40 families with a woman of reproductive age and two children between 2 and 15 years old were sampled at baseline. All the rounds of the study were carried out in women and children in the same households. Hemoglobin, serum ferritin, folic acid, and urinary iodine excretion were analyzed at baseline, one year, and three years later. Results In the third round in 2007 significant increases were observed in the average levels of blood hemoglobin, serum ferritin and folic acid, and urinary iodine. Corresponding decreases in the prevalence of anemia and increases in serum ferritin levels, folic acid, and iodine were found. Conclusions Salt and wheat flour fortification resulted in a significant improvement in the micronutrient status of children and women living in sentinel households in the countries participating in the Asian Development Bank project. Sentinel studies were a cost-effective way of determining potential national effectiveness.

The Chilean Ministry of Health legislated to add folic acid (2.2 mg/100 g) to wheat flour to reduce the risk of neural tube defects (NTD), beginning in January 2000. This policy resulted in a significant increase in serum and red blood cell folate in women of childbearing age 1 year after fortification. The frequency of NTD was studied in all births, both live and stillbirths, in a prospective hospital-based design including 25% of national births during 1999–2000 (prefortification period) and 2001–2002 (postfortification period). During the prefortification period, there was a total of 120,566 newborns, and the NTD rate was 17.1/10,000 births. During the postfortification period (2001–2002) there was a total of 117,704 newborns, and the NTD rate was significantly reduced by 43% to 9.7/10,000 births (RR = 0.57; 95% CI, 0.45 to 0.71). This implies a reduction of 43% in the rate of NTD. The costs per NTD case and infant death averted were 1,200 international dollars (I$) and I$11,000, respectively. The cost per disability-adjusted life year (DALY) averted was I$91, or 0.8% of the country's per capita GDP. On the overall, fortification resulted in net cost savings of I$1.8 million. Fortification of wheat flour with folic acid has proven to be an effective and cost saving strategy for the primary prevention of NTD in a middle-income country in a postepidemiological transition, and in a dramatically short period of time.

Background Anemia is a significant public health problem among schoolchildren in Vietnam. Food fortification is considered one of the most sustainable long-term strategies to control iron-deficiency anemia in Vietnam. The success of a food-fortification program depends on the choice of the food vehicle. Objectives The aim of the present study was to identify an appropriate vehicle for iron fortification to be used in a school-feeding program aimed at improving the iron and anemia status of schoolchildren in rural Vietnam. Methods Children 6 to 8 years of age in two primary schools in Tam Nong District, Phu Tho Province, and their parents were included in this study. The study consisted of three substudies: a food-consumption study with 24-hour recalls of two nonconsecutive days; a food-beliefs study, with focus group discussions, a pile-sorting test, and a food attributes and differences exercise; and a food-acceptance study using noodles and biscuits fortified with sodium iron ethylenediaminetetraacetic acid (NaFeEDTA). Results The average number of meals consumed daily was 3.2 ± 0.4, and the average intakes of energy and iron were 1,218 ± 406 kcal and 7.5 ± 4.0 mg, respectively. Compared with biscuits and instant rice soup, instant noodles were consumed more frequently and in larger portion sizes and are more acceptable as children's food in the culture of the local people. The iron level of the fortified product did not affect the mean consumption of noodles, but a higher level of iron was associated with a lower mean consumption of biscuits ( p < .05). The production process did not affect the NaFeEDTA level in noodles; however, during preparation at least 70% of the iron is leaked into the soup. Conclusions Instant noodles are a suitable vehicle for iron fortification for use in school-based intervention to improve iron-deficiency anemia among primary schoolchildren in rural Vietnam.

The process of applying nutrient intake values (NIVs) for dietary assessment, planning, and implementing programs is discussed in this paper. In addition to assessing, monitoring, and evaluating nutritional situations, applications include planning food policies, strategies, and programs for promotion of optimal nutrition and preventing and treating malnutrition (both over- and undernutrition). Other applications include nutrition education, food and nutrient legislation, marketing and labeling, research, product development, food procurement and trade (import and export), food aid, and therapeutic (clinical) nutrition. Specific examples of how NIVs are used to develop food labels, fortification policies, and food-based dietary guidelines are described. Applications in both developed and developing countries are also described. In summary, NIVs are the scientific backbone of all aspects of nutrition policy in countries and regions worldwide.

The conceptual framework for the various NIVs is depicted in figure 1 along with the methodological approaches and applications. The NIVs consist of two values derived from a statistical evaluation of data on nutrient requirements, the average nutrient requirement (ANR), or nutrient toxicities, the upper nutrient level (UNL). The individual nutrient levelx (INLx) is derived from the distribution of average nutrient requirements. The percentile chosen is often 98%, which is equivalent to 2 SD above the mean requirement. Concepts underlying the NIVs include criteria for establishing a nutrient requirement, e.g., ferritin stores, nitrogen balance, or serum vitamin C. Once the requirement for the absorbed nutrient is determined, it may be necessary to adjust the value for food sources, i.e., bioavailability, or host factors, such as the effect of infection on nutrient utilization. Other concepts that committees may want to consider when establishing NIVs include the effects of genetic variation on nutrient requirements and the role of the nutrient in preventing long-term disease. Two fundamental uses of NIVs are for assessing the adequacy of nutrient intakes and for planning diets for individuals and populations. Establishing the NIV using the statistical framework proposed in this report improves the efficacy of the values for identifying risks of nutrient deficiency or excess among individuals and populations. NIVs also are applied to a number of aspects of food and nutrition policy. Some examples include regulatory issues and trade, labeling, planning programs for alleviating public health nutrition problems, food fortification, and dietary guidance.

Following the 2008 Wenchuan earthquake, the Chinese government instituted an infant and young and child nutrition program that included promotion of in-home fortification of complementary food with ying yang bao (YYB), a soy-based powder containing iron, 2.5 mg as iron-EDTA and 5 mg as ferrous fumarate, and other micronutrients. Ying yang bao was provided to participating families in 8 poor rural counties in Sichuan, Shaanxi, and Gansu provinces by the Ministry of Health. We assessed hemoglobin levels among infants and young children (IYC) aged 6 to 23 months at baseline in May 2010 (n = 1290) and during follow-up in November 2010 (n = 1142), May 2011 (n = 1118), and November 2011 (n = 1040), using the Hemocue method. Interviewers collected basic demographic information and child feeding practices from the children’s caretakers. Altitude-adjusted hemoglobin level averaged 10.8 g/dL, and total anemia prevalence was 49.5% at baseline. Average hemoglobin was 11.3 g/dL at 6 months, 11.6 g/dL at 12 months, and 11.7 g/dL at 18 months after introduction of YYB. Moderate anemia (hemoglobin: 70-99 g/dL) decreased from 20.3% at baseline to 7.5%, 5.8%, and 7.3% after 6, 12, and 18 months of home fortification, respectively ( P < .001), whereas mild anemia (hemoglobin: 100-110 g/dL) decreased from 29.0% to 16.7%, 18.1%, and 15.4%, respectively ( P < .001). Among infants aged 6 to 23 months, 95% had regularly been fed YYB during the observation period. Regression analysis showed that the duration of YYB consumption and number of sachets consumed per week correlated positively with hemoglobin levels and negatively with anemia rates. Home food fortification with YYB is feasible and effective for nutrition promotion among IYC in high-risk regions of China.

Background Simple-to-use quantitative methods are needed to check the adequacy of vitamin A fortification levels. Objective To assess the capacity of a portable fluorometer (iCheck FLUORO) and its test kit vials (iEx Mila) to quantify retinyl palmitate in fortified milks, flours (wheat, maize), and sugar. Methods The portable fluorometer was assessed in a three-step procedure to determine its working range and linearity, intra-assay precision, and interperson precision. Measurements were compared with the results obtained by high-performance liquid chromatography (HPLC), commonly regarded as the standard method for vitamin A analysis. Results The portable fluorometer (iCheck FLUORO) and its test kit vials (iEx Mila) precisely determined the vitamin A contents in fortified flours, sugar, and milks. Its working range was 1 to 10, 0.5 to 3.0, and 5 to 15 mg retinol equivalents (RE) kg−1 for flours (wheat and corn), milks, and sugar, respectively; these values are in accordance with the World Health Organization recommendations for food fortification in least developed countries. The limits of detection are higher than those of HPLC but are all satisfactory (< 1.46 mg RE kg−1). The coefficients of variation within and between observers were satisfactory, especially for sugar and milk. Conclusions The linear relationship between the data from the portable fluorometer and the HPLC data confirms that the portable fluorometer provides a good determination of the vitamin A content of the fortified products in the tested range.

Traditionally, the main strategies used to control micronutrient deficiencies have been food diversification, consumption of medicinal supplements, and food fortification. In Tanzania, we conducted efficacy trials using a dietary supplement as a fourth approach. These were randomized, double-blind, placebo-controlled efficacy trials conducted separately first in children and later in pregnant women. The dietary supplement was a powder used to prepare an orange-flavored beverage. In the school trial, children consumed 25 g per school day attended. In the pregnancy trial, women consumed the contents of two 25-g sachets per day with meals. This dietary supplement, unlike most medicinal supplements, provided 11 micronutrients, including iron and vitamin A, in physiologic amounts. In both trials we compared changes in subjects consuming either the fortified or the nonfortified supplement. Measures of iron and vitamin A status were similar in the groups at the baseline examination, but significantly different at follow-up, always in favor of the fortified groups. Children receiving the fortified supplement had significantly improved anthropometric measures when compared with controls. At four weeks postpartum, the breast milk of a supplemented group of women had significantly higher mean retinol content than did the milk of mothers consuming the nonfortified supplement. The advantages of using a fortified dietary supplement, compared with other approaches, include its ability to control several micronutrient deficiencies simultaneously; the use of physiologic amounts of nutrients, rather than megadoses that require medical supervision; and the likelihood of better compliance than with the use of pills because subjects liked the beverage used in these trials.

The Global Alliance for Improved Nutrition (GAIN) was launched at the United Nations General Assembly Special Session on Children in May 2002 as a global and regional alliance of public private and civic groups committed to eliminating micronutrient deficiencies. The Bill & Melinda Gates Foundation provided GAIN with its principal funding which has been complemented by grants from international and bilateral agencies. GAINs vision is of a world in which malnutrition is no longer a human and social development constraint. In May 2002 the UN General Assembly Special Session on Children re-emphasized the micronutrient goals of the early 1990s: Achieving the sustainable elimination of vitamin A deficiency by 2010 reducing anaemia prevalence including iron deficiency by one third by 2010 and virtually eliminating iodine deficiency disorders by 2005; accelerating progress towards reduction of other micronutrient deficiencies through dietary diversification food fortification and supplementation. (excerpt)

Background Observed-Weighed Food Record Surveys (OWFR) are regarded as the most precise dietary assessment methodology, despite their recognized shortcomings, which include limited availability, high cost, small samples with uncertain external validity that rarely include all household members, Hawthorne effects, and using only 1 or 2 days to identify “usual intake.” Although Household Consumption and Expenditures Surveys (HCES) also have significant limitations, they are increasingly being used to inform nutrition policy. Objective To investigate differences in fortification simulations based on OWFR and HCES from Bangladesh. Methods The pre- and postfortification nutrient intake levels from the two surveys were compared. Results The total population-based rank orderings of oil, wheat flour, and sugar coverage were identical for the two surveys. OWFR found differences in women's and children's coverage rates and average quantities consumed for all three foods that were not detected by HCES. Guided by the Food Fortification Formulator, we found that these differences did not result in differences in recommended fortification levels. Differences were found, however, in estimated impacts: although both surveys found that oil would be effective in reducing the prevalence of inadequate vitamin A intake among both subpopulations, only OWFR also found that sugar and wheat flour fortification would significantly reduce inadequate vitamin A intake among children. Conclusions Despite the less precise measure of food consumption from HCES, the two surveys provide similar guidance for designing a fortification program. The external validity of these findings is limited. With relatively minor modifications, the precision of HCES in dietary assessment and the use of HCES in fortification programming could be strengthened.

The Kingdom of Morocco launched the flour and oil fortification stage of its National Micronutrient Program in December 2000. The vitamin A (oil) and iron (flour) fortification components of the program are based on the 1994 and 1996 national and regional surveys, which showed that 38% and 40.6% of children under five years of age, respectively, were iron and vitamin A deficient. Morocco is following the example of many countries that fortify their salt with iodine and flour with iron, folate, and/or B vitamins. In addition, it is innovative in including vitamin A–fortified oil in its pioneering fortification program, the first in North Africa. This paper concerns the advocacy and consensus-building components in support of iron, vitamin B, and folatefortified flour and for vitamin A–fortified oil (iodized salt began in 1996). As part of its efforts to implement a sustainable food-fortification strategy, the Ministry of Health has already launched a series of activities. The selection of flour and oil to fortify is based on food-consumption patterns. Hydrogenated cooking oil was identified as a good vehicle for fortification because it is centrally processed and over 90% of households use it daily for a variety of cooking purposes. Oil is an excellent fortification vehicle for vitamin A because it is a fat-soluble vitamin. Flour was identified as a good vehicle for iron fortification because 95% of households use it as the main ingredient in bread. The entire population consumes centrally processed flour, even households that also use homemade flour. This is because about one million metric tons of centrally processed flour are subsidized by the Government, at a savings of at least 50% compared with nonsubsidized flour. One innovation of the program is to launch fortification for the general public at the beginning of Ramadan, a month-long religious period, when oil and flour consumption increase significantly.

Food fortification as a strategy for controlling vitamin A deficiency was mooted in Zambia way back when a technical committee was formed following a multisectoral workshop to explore possible food vehicles for vitamin A fortification. The choice of sugar as a vehicle was that it was centrally produced and therefore easy to subject to quality control. Moreover, more than 50% of the households consumed sugar. This initiative was explored with the private firm Zambia Sugar Plc, who saw it as a challenge for them to demonstrate their social responsibility to the public. This marked the beginning of a long-term partnership between the private and public sectors in Zambia. The initiative entailed embracing new technology, securing new equipment, and retraining and orienting staff from both the private and public sectors on the fortification process. Nothing was left to chance. While the orientations were ongoing, the legal framework to govern the standards of the new product was developed. These standards centered on its quality, safety, and labeling. The opinions of the beneficiaries of the fortification program were sought. Most welcomed the idea except for some concern about the added costs, possible toxicity, and accessibility of the new product. The education campaigns addressed these and other concerns.

Many at-risk populations in developing countries are vitamin A deficient. Improvement in the vitamin A status of preschool children would increase their chances of survival and improve their health. Progress has been made in combating severe forms of vitamin A deficiency, yet the extent of subclinical vitamin A deficiency is worrisome. Strategies such as supplementation, food fortification, and dietary diversification have had some impact, but efforts must be made to enhance their effectiveness. One promising strategy is to increase women's access to food-processing technologies that extend the availability of vitamin A and provitamin vitamin A–rich foods, reduce nutrient losses due to traditional processing methods, and improve the hygienic and nutritional quality of the dried food products. Because women are key to household nutrition, improving their access to such technologies would increase women's productivity and enhance the effectiveness of their nutrition-promoting behaviors. The Tanzania Food and Nutrition Centre (TFNC) within the Ministry of Health, and working with the Ministries of Agriculture and Livestock Development and Community Development, Children and Women's Affairs, implemented an intervention research study in rural Tanzania to promote women's adoption of improved solar-drying technologies for preserving vegetables and fruits and to improve children's dietary intake of provitamin A–containing foods. Children whose mothers adopted the improved solar dryers consumed significantly more foods rich in vitamin A and provitamin A (p < .001). The β-carotene content of green leafy vegetables dried in the improved enclosed dryers was better than that of vegetables dried using traditional methods. These results suggest opportunities to reduce seasonal subclinical deficiencies among children in this semiarid rural area of Tanzania.

The control of vitamin A deficiency is a realizable goal that needs to be addressed through a combination of interventions. Among these, fortification of commonly eaten foods and condiments has great potential to help realize this goal. Fortification offers a number of strategic advantages, because it is cost effective, builds on existing food processing and delivery systems, and enhances sustainability. Proven vehicles for vitamin A fortification that are relevant for Africa include sugar, oils and fats, and cereal flours. Fortified foods cannot be expected to reach all deficient populations. However, for the large and expanding populations of all socioeconomic classes that regularly purchase and consume commercially processed foods, fortification can make an enormous difference. For those who do not have easy access to commercially processed foods, fortification at community-level mills and the use of encapsulated micronutrient sprinkles are promising technologies. Although most technologies described in this paper are ready for scale-up and large-scale application, there are a number of steps to be undertaken in order to ensure effective programs, including appropriate advocacy and communication, collaboration among several sectors, food regulations and standards, and quality assurance and monitoring.

In recent years, increasing attention has been drawn to the relatively slow pace of progress in intervention efforts against micronutrient deficiencies in sub-Saharan Africa. Recent data indicate that the problem of micronutrient deficiencies remains severe, a situation compounded by inadequacy of institutional capacities and resources required for implementing well-defined control strategies. Supplementation programmes started in earnest after the 1992 International Conference on Nutrition. More recently, there has been an increase in the rate of coverage of vitamin A supplementation of children under five years of age, attributed to the integration of vitamin A capsule distribution into national immunization days. However, a major constraint to vitamin A capsule delivery is a poorly functioning health infrastructure. Transportation facilities are poor, and there are shortages of equipment and trained personnel. Food fortification, which was initially not considered a front-line approach because of the lack of infrastructural facilities in most countries, is currently being pursued with new ideas for adapting existing technologies to local resources and needs. Early attempts at developing food-based strategies involved promoting the production and consumption of vitamin A– rich foods as well as encouraging small-scale animal production. A major shortcoming of these earlier food-based interventions is a lack of quantifiable and convincing data demonstrating impact. There is a growing movement to involve women in intervention programmes. Africa is primarily agrarian. Micronutrient intervention efforts have not fully exploited the untapped potential of the existing food systems and the immense human resources of the agricultural sector.

The strengths and weaknesses of the food fortification programme for the elimination of vitamin A deficiency in the Philippines were identified based on availability of supporting data, fortification vehicles, fortification technology, government action, and support from various sectors. the programme has strengths in all aspects. Available data on the prevalence of vitamin A deficiency and vitamin A intake, recommended dietary allowances, and guidelines on fortification of foods were used in the development of the programme. the vehicles are widely consumed and centrally processed. the fortificants used were suitable to the specific vehicles. the efficacy of vitamin A–fortified margarine and pandesal bread has been proven. the development of a strategic plan for food fortification, the formulation of fortification legislation, and the implementation of the Sangkap Pinoy Seal programme have been supported by government action at the executive and legislative levels. the food industry has provided support in the establishment of the fortification technology. Non-governmental and international agencies, academia, and the media continue to provide assistance in the implementation of the programme. One of the weaknesses of the programme is that there is no clear policy on food fortification. the programme remains a component of the Plan of Action for Nutrition and the National Micronutrient Operations Plan. The Sangkap Pinoy Seal programme, which encourages the fortification of any food product, has caused a proliferation of fortified non-staple foods in the market. Foreign exchange continues to affect the sustainability of the programme. the effectiveness of other fortified foods still needs to be determined. the programme, with all its strengths, shows great promise for sustainability. the weaknesses of the programme should, however, be addressed urgently by all concerned sectors to meet the programme's objectives.

Vitamin A deficiency is still considered a major nutritional problem in the developing world. Increasing evidence of the role of vitamin A in the control of both morbidity and mortality is a point of great concern. Vitamin A supplementation began several years ago, and it still continues in many countries. However, there is a gradual realization that one of the most effective and sustainable ways to overcome vitamin A deficiency is through food-based strategies, which become a way of life. the most effective way to achieve this is by the following methods, in order of priority: dietary diversification (food supplementation, horticultural interventions, management of proper distribution, and availability of vitamin A–rich foods), nutrition education on all issues related to vitamin A (e.g., sources of vitamin A, importance of and need for vitamin A, methods of obtaining vitamin A–rich foods, and community involvement and participation in the process), and food fortification (identification of foods that can be fortified, development of proper cost-effective methods taking into account local food tastes and availability, and development of a mechanism to reach the most needy). This paper summarizes various case studies to ascertain the effectiveness of the different approaches.

Fortification is an important component of the Philippine Plan for Action on Nutrition. Several programmes are described for the fortification of commonly consumed foods, such as rice, margarine, sugar, salt, oil, and wheat flour, with essential micronutrients, especially vitamin A, iron, and iodine, to satisfy dietary gaps for these nutrients. The overall programme is designed to be spearheaded and implemented by the food industry, while the government is to provide necessary support through policy, technology development and transfer, and incentives to encourage the participation of food manufacturers. The objective of the government's Sangkap Pinoy seal programme is to encourage food manufacturers to market high-quality fortified food products. The seal is awarded to manufacturers who are able to meet standards for fortifying products with vitamin A, iron, or iodine. The seal makes the general public aware of the availability of fortified foods with assurance of quality and, thus, encourages consumption of fortified products. The prerequisites for a successful food-fortification intervention include advocacy, technology development and testing, stability studies, market testing, and field trials. Most fortification efforts have fulfilled these requirements, with the exception of a field trial to determine the efficacy of a fortified food in improving the nutrient status of a target group. Simple, rapid, and low-cost assessment methods to determine fortification levels must be developed to assist food manufacturers in their quality assurance monitoring activities. Moreover, the skills and abilities of village nutrition workers must be harnessed for monitoring fortified foods at the village or household level.

This article reviews the fortification of staple foods in the prevention of micronutrient deficiencies. Fortification of salt with iodine that of wheat flour with iron vitamins B1 and B2 and niacin and that of milk and margarine with vitamins A and D was developed in 1920s and 1940s in industrialized countries. Throughout the world about 254 million children were found to be vitamin A deficient while 2.2 billion and 1 billion people suffer from iron and iodine deficiencies respectively. The World Summit for Children the WHO the UN Childrens Fund and the US Agency for International Development adopted a plan of action with the objective of eliminating vitamin A iron and iodine deficiencies. The approach includes food fortification food supplementation and dietary diversification. In conclusion food fortification is considered an inexpensive and cost-efficient solution in the eradication of micronutrient deficiencies among low-income people pregnant women and young children.

The Food and Agriculture Organization/World Health Organization (FAO/WHO) International Conference on Nutrition (ICN), held in Rome in December 1992, recognized the widespread occurrence of micronutrient deficiencies, particularly in developing countries. The conference recognized food-based approaches as the most effective way to address existing micronutrient deficiencies. These approaches must include appropriate strategies to assure dietary diversification, improved food availability, food preservation, nutrition education, and food fortification. The final report of the conference included strategies and actions for preventing and controlling specific micronutrient deficiencies. It was proposed to ensure and legislate the fortification of foods or water with necessary micronutrients, where possible, when existing supplies fail to provide adequate levels in the diet. Food fortification has been successfully used in both developed and developing countries as one strategy to address micronutrient deficiencies. The primary purposes of food legislation are to protect the health of the consumer, protect the consumer from fraud, and facilitate trade. In the case of fortified foods, the target population must be protected from receiving either toxic or nutritionally ineffective levels of micronutrients. Legislation may be necessary to require adequate control over this fortification process by the food processors to ensure that levels of micronutrients are consistently within acceptable limits. Legislation may also be required to prohibit the addition of nutrients to commodities where it is nutritionally unnecessary or unsafe or where fortification may create an erroneous impression as to the nutritional value of the food. Any legislation regarding food fortification should incorporate the standards, recommendations, and guidelines of the Codex Alimentarius. The World Trade Organization (WTO) Agreement on the Application of Sanitary and Phytosanitary Measures (the SPS Agreement) and the WTO Agreement on Technical Barriers to Trade (the TBT Agreement) have placed new importance on Codex standards, guidelines, codes, and recommendations.

Iron deficiency, one of the most prevalent problems of micronutrient malnutrition, occurs in both developing and industrialized countries. The impact of iron deficiency and iron-deficiency anaemia on the individual can result in lifelong disadvantages. The causes of the problem are many, but the principal cause is lack of iron-rich food. The International Conference of Nutrition sponsored by the World Health Organization (WHO) in Rome in 1992 estimated that over 2,000 million people worldwide suffer from anaemia, most of which is related to iron deficiency. Infants and young children are decidedly vulnerable groups, for a number of reasons. Their food choices are limited. The amount of food they consume is relatively low, but the demand for nutrients is high. Experience from industrialized countries indicates that one of the best strategies to eliminate or markedly reduce micronutrient malnutrition globally is through food fortification, with the goal of increasing the level of consumption of added nutrients to improve the nutritional status of the target population.The current recommendation for infant feeding to ensure good iron status is breastfeeding for at least four to six months. The range of iron bioavailability in breastmilk is 50% to 80%, probably because of the presence of lactoferrin, which enhances iron absorption. Thus, it is not surprising that the prevalence of iron-deficiency anaemia in early infancy is inversely correlated with the incidence of breastfeeding. If breastfeeding is not possible, iron-fortified formula should be substituted. By about four to six months, an exogenous source of iron is required. The limited food choices and the few iron-rich foods generally available make fortification of complementary food mandatory. Iron-fortified cereal has been demonstrated to be one of the most effective food vehicles in combating iron deficiency. It is usually the first solid introduced to infants to supplement breastmilk. Clinical research in China, Chile, and Canada has shown that the iron is bioavailable and the iron-fortified infant cereals are effective in the prevention and treatment of iron deficiency. In the United States the use of iron-fortified infant formula and cereal has significantly reduced iron deficiency among infants and pre-schoolers. Many other examples illustrate the importance of the food industry and food fortification in combating micronutrient malnutrition. The Global Plan of Action advocated collaboration among governments, non-governmental organizations, the private sector, local communities, etc. in the elimination of the problem. It is clear that without the food industry, iron-rich foods will not be available. Support and recognition of public health organizations must be given to the food industry to encourage the development of affordable and culturally appropriate iron-fortified foods.