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Objective: Mandatory folic acid fortification of enriched grains has reduced neural tube defect prevalence in several countries. We examined salt as an additional vehicle for folic acid fortification. The primary objective was to examine the change in serum folate concentration after 1 month of consumption of fortified iodised salt with folic acid (FISFA) among women of reproductive age. The secondary objectives were to examine (1) the feasibility of implementing FISFA intervention and (2) the acceptability of FISFA., Design: We conducted a pre–post intervention study (January–April 2023). Participants received a FISFA saltshaker with the study salt (1 g of sodium chloride salt fortified with 100 mcg of folic acid) to use instead of regular table salt for 1 month. Serum folate was measured using the Elecsys Folate-III immunoassay method at baseline and 1-month endpoint. Change in serum folate was assessed using a two-tailed Wilcoxon signed rank test for paired samples., Setting: Metropolitan city, Southern USA., Participants: Non-pregnant, 18–40-year-old women who lived alone/with a partner., Results: Thirty-two eligible women consented to participate, including eleven non-Hispanic-White, eleven non-Hispanic-Black and ten Hispanic. Post-intervention, there was a significant increase in median serum folate concentration of 1·40 nmol/l (IQR 0·74–2·05; P < 0·001) from 24·08 nmol/l to 25·96 nmol/l in an analytical sample of n 29. An increase was seen in 28/29 (93 %) participants. Feasibility: 100 % study consent and compliance. FISFA acceptability: 25 d average use; 1·28 g average daily intake; 96·7 % and 90 % reported taste and colour of FISFA as highly acceptable, respectively., Conclusions: FISFA is an effective approach to increasing serum folate concentrations among women of reproductive age. Findings should be replicated in a larger study.

Background: Achachairu is an exotic fruit that is being studied for its bioactive compound composition. However, there is scarce information on the properties of its by-products and their incorporation into food. In this study, achachairu peels were used to obtain phenolic-rich and sustainable ingredients. Furthermore, their potential for use in the fortification of food, particularly cereal-based products, was evaluated. Different ratios of ethanol:water were used to extract the phenolic compounds from achachairu (100:0, 90:10 and 70:30). The optimal extract was characterised regarding its total phenolic content (TPC) and antioxidant, antimicrobial and anti-enzymatic properties. Finally, achachairu peel powder and extract were incorporated into bread and their influence on the texture, antioxidant properties and shelf life of the product was evaluated., Results: High-performance liquid chromatographic analysis showed that the 90:10 extract contained a higher phenolic composition than the other samples. The achachairu extract presented a TPC of 88.7 mg GAE  g -1 , good antioxidant capacity towards DPPH and ABTS radicals and the capacity to inhibit the activity of α-amylase by almost 80%. The addition of achachairu peel powder and extract to bread increased its hardness, chewiness and gumminess, not affecting the remaining texture parameters. An increase in the TPC, antioxidant properties and shelf life of the product was also observed., Conclusion: This study proves the potential for achachairu by-products incorporated into cereal-based products to improve their biological properties while extending the food shelf life. © 2024 Society of Chemical Industry., (© 2024 Society of Chemical Industry.)

The high protein content of several microalgae species makes them an excellent addition to various food products, increasing their nutritional value. In this study, vegan basil pesto was designed and enriched with 1% and 2% Arthrospira platensis (spirulina). The pesto obtained was characterized by increased protein content (up to 40% more) and had a rich mineral composition, including up to three times more iron and 25% more calcium, among others. The increase of spirulina addition in the pesto also increased the content of polyphenols (up to 50% more) and flavonoids (up to 39% more). The fortified products had higher antioxidant activity against ABTS (up to 484.56 ± 2.16 μM Trolox/g) and DPPH (up to 392.41 ± 13.58 μM Trolox/g). The addition of spirulina will affect the hardness of the sauce, while in the other texture parameters (adhesiveness, springiness, and cohesion), there were no significant differences between the control and spirulina-fortified pesto. Although the pesto with spirulina was significantly darker in color (ΔE 8.83 and 12.05), consumers still rated it highly. All quality parameters of pesto with a 1% spirulina addition were rated the highest, contributing to the highest overall rating of the product (4.56). An increase in spirulina addition to 2% resulted in a decrease in the overall pesto rating (4.01), but still remains a good result compared to the control (4.22).

The health benefits of vitamin B9 (folate) are well documented, particularly in regard to neural tube defects during pregnancy; however, much remains to be learned regarding the health effects and risks of consuming folic acid supplements and foods fortified with folic acid. In 2020, our laboratory conducted a population-based analysis of the Food Fortification Initiative (FFI) dataset to determine the strength of the evidence regarding the prevalence of neural tube defects (NTD) at the national level in response to mandatory fortification of cereal grains with folic acid. We found a very weak correlation between the prevalence of NTDs and the level of folic acid fortification irrespective of the cereal grain fortified (wheat, maize, or rice). We found a strong linear relationship between reduced NTDs and higher socioeconomic status (SES). Our paper incited a debate on the proper statistics to employ for population-level data. Subsequently, there has been a large number of erroneous citations to our original work. The objective here was to conduct a bibliometric analysis to quantitate the accuracy of citations to Murphy and Westmark's publication entitled, "Folic Acid Fortification and Neural Tube Defect Risk: Analysis of the Food Fortification Initiative Dataset". We found a 70% inaccuracy rate. These findings highlight the dire need for increased rigor in citing scientific literature, particularly in regard to biomedical research that directly impacts public health policy.

Background: In many low-income countries, iron deficiency (ID) and its anemia (IDA) pose significant health challenges, particularly among females and girls. Finding sustainable and effective solutions to address this issue is critical., Objectives: This study aimed to evaluate the efficacy of incorporating iron-fortified lentils (IFLs) into the diets of rural Bangladeshi adolescent girls on their body iron (Fe) status., Methods: A community-based, double-blind, cluster-randomized controlled trial involved n = 1195 girls aged 10-17 y. A total of 48 adolescent clubs (n = ∼27 girls each) were randomized into 3 groups: 1) 200 g cooked IFLs, 2) 200 g cooked noniron-fortified lentils (NIFLs), and 3) a control group with no lentils (usual dietary intake). The intervention, administered 5 days a week for 85 feeding days, provided ∼8.625 mg Fe from each serving of IFLs and 2.625 mg from NIFLs. Blood samples collected at baseline, midpoint (42 feeding days), and endpoint (85 feeding days) assessed key Fe and inflammation biomarkers. Statistical analyses were filtered for inflammation., Results: Although all groups experienced a decline in Fe status over time, the IFL group exhibited a significantly reduced decline in serum ferritin (sFer -7.2 μg/L), and total body iron (TBI -0.48 mg/kg) level compared with NIFL (sFer -14.3 μg/L and TBI -1.36 mg/kg) and usual intake group (sFer -12.8 μg/L and TBI -1.33 mg/kg). Additionally, those in the IFL group had a 57% reduced risk of developing clinical ID (sFer <15 μg/L) compared with the usual intake group., Conclusions: Our findings suggest that incorporating IFLs into the diet can help mitigate a decline in sFer, indicating a positive impact on the body Fe status of adolescent girls. This research underscores the potential role of fortified foods in addressing ID and IDA in vulnerable populations, emphasizing the significance of food-based interventions in public health., Trial Registration Number: This trial was registered at the clinicaltrials.gov on May 24, 2018 (https://clinicaltrials.gov/study/NCT03516734?locStr=Bangladesh&country=Bangladesh&distance=50&cond=Anemia&intr=Iron%20fortified%20lentils&rank=1) as NCT03516734., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

There has been growing interest in the potential of vitamin D food fortification in Europe as a means of addressing low vitamin D status. The WHO-FAO suggest that choosing a suitable food vehicle and ensuring the combination of the food vehicle and the fortificant will be efficacious and effective are of key importance to a successful food fortification programme. Our key objective was to conduct a systematic review and meta-analysis to investigate the effect of various animal- and plant-based food vehicles fortified with vitamin D (as D 3 or D 2 ) on circulating 25-hydroxyvitamin D [25(OH)D] concentrations. A list of prioritised food vehicles was established and we searched PubMed, Embase, Scopus and Web of Science for randomised controlled trials (RCTs) which used these vehicles individually, and which met prespecified criteria. The searches identified 49 papers which described suitable RCTs using vitamin D-fortified bread/savoury biscuits (n = 5), orange juice (n = 5), UV-mushrooms (n = 8), cheese (n = 3), yogurt (n = 5), fluid milk (n = 13), powdered milk (n = 5), eggs (n = 2), edible oils (n = 4), or breakfast cereal (n = 1). No suitable RCTs were identified for rice, maize flour, butter, margarine or dairy spreads, plant-based milk or yogurt alternatives. Random-effects meta-analyses of each food vehicle individually indicated weighted mean differences (WMD) in 25(OH)D in the range ∼9-35 nmol/L (3-15 RCT arms, depending on vehicle), and all statistically significant (P < 0.01-0.0001), with the exception of UV-mushrooms (P = 0.06). Heterogeneity was variable (I 2 =33-99%, depending on vehicle), but subgroup analysis based on vitamer and dose reduced it in some instances. Sub-group analysis on the basis of whether the food vehicles were from plant-based or animal-based origin showed no significant difference in WMD (15.2 versus 15.9 nmol/L, respectively; P = 0.48). These results support the use of various animal- and plant-based food vehicles for vitamin D fortification to improve circulating 25(OH)D concentrations in populations. This work was registered with PROSPERO as CRD42023439883., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Purpose: This study investigates intakes of risk micronutrients from non-fortified foods, fortified foods and food supplements in different age and gender sub-groups of the Dutch population., Methods: This is a secondary analysis of the Dutch National Food Consumption Survey (DNFCS 2012-2016, N = 4313, 1-79 years). The proportion of the population with Habitual Intakes below the Estimated Average Requirement (EAR) and above the Upper Level (UL) for calcium, iron, zinc, vitamin A, vitamin B6, folate, vitamin D and vitamin E from non-fortified foods, fortified foods and total intake including food supplements was calculated using Statistical Program to Assess Dietary Exposure (SPADE)., Results: More than 50% of the population had an intake below the EAR for calcium, iron, vitamin D and folate. Intakes were inadequate for certain sub-groups for the other vitamins and minerals. Adolescents and women were the population sub-groups most likely to have an intake below the EAR. For zinc, vitamin A and folic acid, more than 1% of toddlers exceeded the UL from the total intake. A negligible proportion exceeded the UL for the other vitamins and minerals., Conclusion: Inadequate intakes were found for several micronutrients in various population sub-groups despite an apparently well-nourished population. Intakes of zinc, folic acid and vitamin A from food supplements in toddlers and preschoolers should be investigated further to ensure they do not exceed recommended amounts. These results can be used to inform policy makers and to design nutritional interventions to improve micronutrient intakes in the Netherlands., (© 2023. The Author(s).)

Background: Vitamin D deficiency is a prevalent problem in worldwide healthcare related to several system disorders. Food fortification as a solution is associated with several challenges including insufficient coverage of the entire population, required degree of fortification, the vehicles used for fortification and potential toxicity. This study aimed to determine the optimal amount of vitamin D for fortification without surpassing the upper intake level (UL) of intake at the 95th percentile of the Iranian population and compare two methods of food fortification., Methods: This study is aimed to develop a model of two different fortifying approaches related to an available dataset called MASHAD cohort study. The dataset comprised demographic and nutritional data of 9704 Iranian individuals living in the Greater Mashhad region. The first approach was a computational method necessary to implement a range of eight foods and calculate the optimal approach. In the second case, we used the European formula method called ILSI., Results: To find the appropriate value for fortification, we calculated the consumption of 400 IU and 1000 IU supplements of vitamin D. Three micrograms per 100 g in each food was the optimal output. We also used Flynn and Rasmussen's formula on our data. Using these methods, we found that 2.1 micrograms per 100 kcal provides the best result. Hence, using the two different approaches, the results appear to be consistent and promising., Conclusion: One interesting finding was that supplement consumption did not greatly affect the impact of fortification. This observation may support the hypothesis to determine the amount of fortification, and we can ignore the study population's supplement consumption., (© 2023 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Information on fortifiable food consumption is essential to design, monitor and evaluate fortification programmes, yet detailed methods like 24-h recalls (24HRs) that provide such data are rarely conducted. Simplified questionnaire-based methods exist but their validity compared with 24HRs has not been shown. We compared two simplified methods (i.e., a household food acquisition and purchase questionnaire [FAPQ] and a 7-day semiquantitative food frequency questionnaire [SQ-FFQ]) against 24HRs for estimating fortifiable food consumption. We assessed the consumption of fortifiable wheat flour and oil using a FAPQ and, for wheat flour only, a 7-day SQ-FFQ and compared the results against 24HRs. The participants included children 12-18 months (n = 123) and their mothers 18-49 years selected for a study assessing child vitamin A intake and status in Mandaluyong City, Philippines. For fortifiable wheat flour, the FAPQ estimated considerably lower mean intakes compared to 24HRs for children and mothers (2.2 vs. 14.1 g/day and 5.1 vs. 42.3 g/day, respectively), while the SQ-FFQ estimated slightly higher mean intakes (15.7 vs. 14.1 g/day and 51.5 vs. 42.3 g/day, respectively). For fortifiable oil, the FAPQ estimated considerably higher mean intakes compared to 24HRs for children and mothers (4.6 vs. 1.8 g/day and 12.5 vs. 6.1 g/day, respectively). The SQ-FFQ, but not the FAPQ, generated useful information on fortifiable food consumption that can inform fortification programme design and monitoring decisions in the absence of more detailed individual-level data. Potential adaptations to improve the FAPQ, such as additional questions on foods prepared away from home and usage patterns, merit further research., (© 2023 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.)

Food fortification is an effective strategy to address vitamin A (VitA) deficiency, which is the leading cause of childhood blindness and drastically increases mortality from severe infections. However, VitA food fortification remains challenging due to significant degradation during storage and cooking. We utilized an FDA-approved, thermostable, and pH-responsive basic methacrylate copolymer (BMC) to encapsulate and stabilize VitA in microparticles (MPs). Encapsulation of VitA in VitA-BMC MPs greatly improved stability during simulated cooking conditions and long-term storage. VitA absorption was nine times greater from cooked MPs than from cooked free VitA in rats. In a randomized controlled cross-over study in healthy premenopausal women, VitA was readily released from MPs after consumption and had a similar absorption profile to free VitA. This VitA encapsulation technology will enable global food fortification strategies toward eliminating VitA deficiency.

The need for a profound food system transformation has never been greater. The growing burden of malnutrition has become the new normal, with two billion people who are overweight, over 140 million children under five who are stunted and over two billion people affected by hidden hunger. Food fortification has been recognized as a cost-effective strategy to address micronutrient deficiencies. Small and medium enterprises (SMEs) play a strategic role in the food supply chain in low- and middle-income countries, accounting for over 80% of food sales. It is therefore critical to create an enabling environment to facilitate SMEs' involvement in food fortification practices as a potential solution to tackle all forms of malnutrition. This review highlights SMEs' relevance as agents of change in the food system through food fortification practices and their indirect yet key role in producing nutritious, tasty and affordable foods. It discusses their challenges (e.g., access to long-term finance, sustainable technical assistance, limited capacity), presents solutions and discusses how different actors can help SMEs to overcome these challenges. Furthermore, it presents a relevant public-private partnership case study to demonstrate how SMEs can address the growing burden of malnutrition through food fortification practices, nutrient profiling schemes and demand generation.

Improvement of vitamin D status of the general population has been a challenge for policymakers. We conducted a meta-analysis to evaluate whether vitamin D-fortified products can be a suitable solution for tackling vitamin D deficiency. Our secondary objective was to determine the effect of some variables including age, latitude and BMI on efficacy of this strategy. MEDLINE, PubMed, Embase, Cochrane Library and Google Scholar were searched and 231 studies were found in a preliminary search. After screening of titles and abstracts, 23 studies were selected. Pooled data comparing fortification with vitamin D +/- Ca with control showed statistically significant effect on total 25(OH)D concentrations (2002 participants, mean difference (MD): 25·4 nmol/l, (95 % CI 19·5, 31·3)). The subgroup analysis by duration of intervention (less than 12 weeks v . more than 12 weeks) and type of vehicle (dairy product, juice, grain product, oil and combination of dairy and grain products), isoform of the vitamin (D 3 v . D 2 . < 1000 IU/d) also indicated significant effect of fortification with vitamin D on serum 25(OH)D concentrations. In conclusion, the circulating 25(OH)D response to vitamin D-fortified food consumption is influenced by age, BMI and the baseline 25(OH)D concentrations. Notwithstanding, an average of 2 nmol/l increase in circulating 25(OH)D concentration for each 100 IU vitamin D intake per d is expected for general adult population. These findings can be informative for policymakers to tackle vitamin D deficiency through food fortification strategy.v . < 1000 IU/d) also indicated significant effect of fortification with vitamin D on serum 25(OH)D concentrations. In conclusion, the circulating 25(OH)D response to vitamin D-fortified food consumption is influenced by age, BMI and the baseline 25(OH)D concentrations. Notwithstanding, an average of 2 nmol/l increase in circulating 25(OH)D concentration for each 100 IU vitamin D intake per d is expected for general adult population. These findings can be informative for policymakers to tackle vitamin D deficiency through food fortification strategy.

Purpose: In the Netherlands, margarines and other plant-based fats (fortified fats) are encouraged to be fortified with vitamin A and D, by a covenant between the Ministry of Health and food manufacturers. Frequently, these types of fats are also voluntarily fortified with other micronutrients. The current study investigated the contribution of both encouraged as well as voluntary fortification of fortified fats on the micronutrient intakes in the Netherlands., Methods: Data of the Dutch National Food Consumption Survey (2012-2016; N = 4, 314; 1-79 year.) and the Dutch Food Composition Database (NEVO version 2016) were used to estimate micronutrient intakes. Statistical Program to Assess Dietary Exposure (SPADE) was used to calculate habitual intakes and compared to dietary reference values, separate for users and non-users of fortified fats., Results: Of the Dutch population, 84% could be considered as user of fortified fats. Users consumed mostly 1 fortified fat a day, and these fats contributed especially to the total micronutrient intake of the encouraged fortified micronutrients (vitamins D and A; 44% and 29%, respectively). The voluntary fortification also contributed to total micronutrient intakes: between 7 and 32%. Vitamin D and A intakes were up to almost double among users compared to non-users. Intakes were higher among users for almost all micronutrients voluntarily added to fats. Higher habitual intakes resulted into higher risks of excessive vitamin A-intakes among boys and adult women users., Conclusion: Consumption of fortified fats in the Netherlands resulted into higher vitamin A and D-intakes among users, compared to non-users of these products., (© 2021. The Author(s).)

Calcium intake remains inadequate in many low- and middle-income countries, especially in Africa and South Asia, where average intakes can be below 400 mg/day. Given the vital role of calcium in bone health, metabolism, and cell signaling, countries with low calcium intake may want to consider food-based approaches to improve calcium consumption and bioavailability within their population. This is especially true for those with low calcium intake who would benefit the most, including pregnant women (by reducing the risk of preeclampsia) and children (by reducing calcium-deficiency rickets). Specifically, some animal-source foods that are naturally high in bioavailable calcium and plant foods that can contribute to calcium intake could be promoted either through policies or educational materials. Some food processing techniques can improve the calcium content in food or increase calcium bioavailability. Staple-food fortification with calcium can also be a cost-effective method to increase intake with minimal behavior change required. Lastly, biofortification is currently being investigated to improve calcium content, either through genetic screening and breeding of high-calcium varieties or through the application of calcium-rich fertilizers. These mechanisms can be used alone or in combination based on the local context to improve calcium intake within a population., (© 2021 The Authors. Annals of the New York Academy of Sciences published by Wiley Periodicals LLC on behalf of New York Academy of Sciences.)

Vitamin D intakes and status are low in many countries due to seasonal UVB exposure variation and the fact that few foods are naturally vitamin D rich. Data modelling studies show that vitamin D intakes increase with food fortification, and countries with mandatory fortification policies have higher vitamin D intakes and status compared to countries without. While many foods can be vitamin D fortified, vitamin D bioavailability differs depending on fortification methods, food structure and composition. Randomised controlled trials (RCT) report that vitamin D 2 bioavailability varies between foods, whereas vitamin D 3 is bioavailable from many foods. In vitro studies suggest that altering the lipid composition of fortified foods increases vitamin D 3 absorption. Olive oil increased vitamin D 3 absorption during in vitro digestion compared to other dietary oils. Additionally, when vitamin D 3 was incorporated into micelles formed from in vitro digestion of olive oil, more vitamin D 3 was absorbed compared to other dietary oils. However, in a human postprandial study, a preformed vitamin D 3 micelle dairy drink did not increase vitamin D 3 absorption, and a vitamin D 3 olive dairy drink increased vitamin D 3 absorption in vitamin D insufficient participants only. Action is urgently needed to improve vitamin D intakes and status worldwide. Food fortification improves vitamin D intakes; however, fortification strategies unique to each country are needed. This review will synthesise the literature describing data modelling and intervention trials that assess the safety and efficacy of vitamin D fortification strategies, and those manipulating food composition to alter vitamin D bioavailability from fortified foods. Additionally, RCT examining the impact of vitamin D fortification strategies on vitamin D intakes and status over time are reviewed.

Background: Food fortification as part of the food-first approach in nursing homes is a strategy that may increase energy and protein intake., Objectives: This review aimed to determine the effect of nutrition interventions using fortification, nutrient-dense or enriched food and/or drinks on energy and protein intake in residents living in nursing homes, compared to the standard menu with or without oral nutritional support products. The secondary aim was to identify and synthesise outcomes of these interventions on weight change, nutritional status, acceptability, cost-effectiveness, and cost-benefit., Methods: A systematic search of seven databases was undertaken. After reviewing all titles/abstracts then full-text papers, key data were extracted and synthesised narratively and through meta-analysis. The quality of included studies was assessed using the Quality Criteria Checklist for Primary Research., Results: Of 3,098 articles retrieved, 16 were included, 13 in the meta-analysis. There were 891 participants, with the study duration ranging from four to 26 weeks. The groups receiving the fortified diet had a significantly higher energy intake (Hedges' g = 0.69 (CI 0.36-1.03), p < 0.0001) and protein intake (Hedges' g = 0.46 (CI 0.17-0.74), p = 0.003) compared with the groups receiving the standard menu +/- ONS. The meta-analysis revealed I 2 values of 77% for energy (p < 0.0001) and 60% for protein (p = 0.003), indicating considerable statistical heterogeneity across included studies. Benefits to weight and nutritional status of residents were recorded in some studies. Where reported, cost-effectiveness and cost-benefit of menu fortification/supplementation were variable., Conclusions: This systematic review with meta-analyses has shown that fortified menus may significantly increase energy and protein intakes compared with standard menus in nursing homes. As such, the findings of this review support further use of fortified diets in this setting. Further research is warranted comparing food fortification to standard menus, with a particular focus on evaluating the effect on weight, nutritional status and cost-effectiveness of the intervention., Study Registration: PROSPERO no. CRD42020162796., Competing Interests: Declaration of Competing Interest None., (Copyright © 2021. Published by Elsevier Ltd.)

Adequate iron intake is essential for optimal child development, but iron deficiency and anemia among infants and young children are widespread in low- and middle-income countries. Large-scale food fortification strategies hold great promise for reducing micronutrient deficiencies; however, for children <2 y of age, the impact of such strategies is limited because their intake of staple foods is relatively low and fortification levels are targeted at the adult population. Iron supplementation, iron fortification of foods targeted to infants, and point-of-use fortification with iron-containing products such as multiple micronutrient powders (MNPs) and small-quantity lipid-based nutrient supplements are evidence-based approaches recommended to reduce anemia among infants and young children when used in the right context. Since 2003, the WHO, with support from UNICEF, has recommended the use of MNPs to control iron deficiency. However, the percentage of children with anemia has changed very little over the past 10 y. Five years ago the UN declared a decade of action on nutrition, including World Health Assembly (WHA) targets for maternal, infant, and young child nutrition, yet the WHA set no anemia targets for children. In July 2020 the leaders of 4 UN agencies issued a call for action to protect children's right to nutrition in the face of the COVID-19 pandemic and beyond. Given persistently high rates of anemia among young children, the negative developmental impact, the challenge of meeting iron needs from typical complementary food diets, and the availability of successful evidence-based fortification strategies for this age group, we encourage planners, speakers, and donors at this year's UN Food Systems Summit and the Tokyo Nutrition for Growth Summit to 1) call for the WHA to set anemia targets for infants and young children and 2) promote investment in evidence-based interventions to improve the iron status of young children., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Society for Nutrition.)

Context-specific evidence evaluation is advocated in modern epidemiology to support public health policy decisions, avoiding excessive reliance on experimental study designs. Here we present the rationale for a paradigm shift in evaluation of the evidence derived from independent studies, as well as systematic reviews and meta-analyses of observational studies, applying Hill's criteria (including coherence, plausibility, temporality, consistency, magnitude of effect, and dose-response) to evaluate food fortification as an effective public health intervention against folic acid-preventable (FAP) spina bifida and anencephaly (SBA). A critical appraisal of evidence published between 1983 and 2020 supports the conclusion that food fortification with folic acid prevents FAP SBA. Policy-makers should be confident that with mandatory legislation, effective implementation, and periodic evaluation, food fortification assures that women of reproductive age will safely receive daily folic acid to significantly reduce the risk of FAP SBA. Current evidence should suffice to generate the political will to implement programs that will save thousands of lives each year in over 100 countries., (©The Author(s) 2021. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health.)

Foods with voluntary nutritional additions are a fast-growing sector of the global food industry. In Canada, while the addition of nutrients to foods has been regulated through fortification regulations, parallel policies which aim to encourage product innovation have also allowed for the voluntary addition of nutrients and other novel ingredients to 'supplemented' and 'functional' foods. Concerns have been raised that the consumption of these products may have negative repercussions on population health, such as high nutrient intakes inappropriate for certain population subgroups (e.g., children) and the shifting of dietary patterns to include more unhealthy foods. The aim of this study was to evaluate the prevalence, nutritional quality, and marketing characteristics of foods with added nutrients in the Canadian market. We found many nutritionally-enhanced foods contained high levels of nutrients beyond recommended intakes, despite these nutrients having no evidence of inadequacy in the Canadian population. Additionally, a large proportion of foods with added nutrients had poor nutrient profiles (were deemed 'less healthy' than their non-enhanced counterparts) and carried heavy marketing on their labels, regardless of their nutritional quality. Taken together these findings raise concerns about foods with voluntary nutrient additions and suggest the need to further investigate consumer attitudes and decision-making towards these foods.

In 2014, there was an outbreak of beriberi on Kuria, a remote atoll in Kiribati, a small Pacific Island nation. A thiamine-poor diet consisting mainly of rice, sugar, and small amounts of fortified flour was likely to blame. We aimed to design a food fortification strategy to improve thiamine intakes in Kuria. We surveyed all 104 households on Kuria with a pregnant woman or a child 0-59 months. Repeat 24-h dietary recalls were collected from 90 men, 17 pregnant, 44 lactating, and 41 other women of reproductive age. The prevalence of inadequate thiamine intakes was >30% in all groups. Dietary modeling predicted that rice or sugar fortified at a rate of 0.3 and 1.4 mg per 100 g, respectively, would reduce the prevalence of inadequate thiamine intakes to <2.5% in all groups. Fortification is challenging because Kiribati imports food from several countries, depending on price and availability. One exception is flour, which is imported from Fiji. Although resulting in less coverage than rice or sugar, fortifying wheat flour with an additional 3.7 mg per 100 g would reduce the prevalence of inadequacy to under 10%. Kiribati is small and has limited resources; thus, a regional approach to thiamine fortification is needed., (© 2021 The Authors. Annals of the New York Academy of Sciences published by Wiley Periodicals LLC on behalf of New York Academy of Sciences.)

Surveillance data have highlighted continued disparities in neural tube defects (NTDs) by race-ethnicity in the United States. Starting in 2016, the Food and Drug Administration (FDA) authorized voluntary folic acid fortification of corn masa flour to reduce the risk of neural tube defects (NTDs) among infants of Hispanic women of reproductive age. To assess the impact of voluntary corn masa fortification, cross-sectional data from the National Health and Nutrition Examination Survey (NHANES) 2011-2018 for Hispanic women of reproductive age with available red blood cell (RBC) folate concentrations were analyzed, with additional analyses conducted among Hispanic women whose sole source of folic acid intake was fortified foods (enriched cereal grain products (ECGP) only), excluding ready-to-eat cereals and supplements. RBC folate concentration (adjusted geometric mean) among Hispanic women of reproductive age did not differ between 2011-2016 and 2017-2018, though RBC folate concentration increased significantly among lesser acculturated Hispanic women consuming ECGP only. Concentrations of RBC folate for those born outside the U.S and residing in the U.S <15 years increased from 894 nmol/L (95% CI: 844-946) in 2011-2016 to 1018 nmol/L (95% CI: 982-1162; p < 0.001) in 2017-2018. Primarily Spanish-speaking Hispanic women of reproductive age who only consumed ECGP saw an increase from 941 nmol/L (95% CI: 895-990) in 2011-2016 to 1034 nmol/L (95% CI: 966-1107; p = 0.03) in 2017-2018. By subpopulation, we observed no significant changes in the proportion at risk of NTDs (<748 nmol/L) and no changes in the model-based estimated NTD rates following voluntary corn masa fortification. This analysis suggests that there is a remaining risk among Hispanics for folate sensitive NTDs, though continued monitoring of folate status in future NHANES data cycles will help inform the long-term efficacy of voluntary fortification of corn masa flour.

Although mandatory fortification of oil with vitamin A is efficacious, its effectiveness can be compromised by suboptimal compliance to standards. In this study, we assessed (1) the availability of oil brands across the eight divisions of Bangladesh, (2) fortification quality (the extent to which vitamin A content is aligned with fortification standards) of oil brands and producers and (3) the market volume represented by available edible oil types. We visited different retail outlets in rural and urban market hubs to ascertain available oil brands and bulk oil types and collected samples. We used high-performance liquid chromatography to quantify average vitamin A content and compared them to the national oil fortification standards. Among the 66 packaged brands analyzed, 26 (39%) were not fortified, and 40 (61%) were fortified, with 28 (42%) fortified above the standard vitamin A minimum. Among the 41 bulk oil type composites analyzed, 24 (59%) were not fortified, and 17 (41%) were fortified, with 14 (34%) fortified below and 3 (7%) fortified above the standard minimum. Vitamin A fortification is high for packaged and branded edible oil but low for oil sold in unbranded, loose form. As bulk oil makes up a large proportion of the oil market volume, this means the majority of the oil volume available to the population is either not (25%) or fortified below the standard requirement (39%). Regulatory inspections of producers selling bulk oil should be prioritized to support and incentivize the industry to make all oil traceable and fortified to standard.

The double fortification of salt with iodine and iron has been proposed as a method for the mass prevention of iron deficiency anemia. This article reports on the technical and financial aspects of the production of such double fortified salt (DFS) based on the experiences of current and past producers. It draws contrasts with the established process of fortifying salt solely with iodine particularly examining the cost and complexity of the processes involved. Based on these factors it questions the commercial viability of existing DFS formulations and thus their sustainability as vehicles for the widespread distribution of iron outside a subsidized environment. It makes suggestions for the future development of DFS particularly relating to the development of less expensive iron formulations suitable for use with lower quality salts and identifies key technical and economic areas to be taken into account when considering the production of DFS., (Copyright © The Author(s) on behalf of the American Society for Nutrition 2021.)

Multiple micronutrient deficiencies (MNDs) co-exist, often because of poor intakes and adversely impact health. Habitual diets were assessed in 300 school children (6-17 years old) recruited from two government schools by simple random sampling. Probability of adequacy (PA) for 11 micronutrients and mean probability of adequacy (MPA) was calculated. Haemoglobin, plasma ferritin, folic acid, vitamin B 12 and C-reactive protein were estimated. Descriptive statistics and regression analysis were used to estimate magnitude and factors associated with MNDs. The contribution of fortified foods and/or supplements in addressing inadequacies and excessive intakes was modelled. The PA ranged from 0.04 for folate to 0.70 for zinc, and the MPA was 0.27. Prevalence of anaemia (53%), iron deficiency (57%; ID), iron deficiency anaemia (38%; IDA), folate deficiency (24%) and B 12 deficiency (43%) was high. Dietary inadequacy of iron, zinc and a low MPA was associated with anaemia and IDA. Inclusion of double fortified salt (DFS), fortified rice (FR) or iron folic acid (IFA) supplements individually in habitual diet reduced probability of iron inadequacy significantly from 82% to ≤13%. Inclusion of DFS and FR simultaneously led to disappearance of iron inadequacy, but risk of excessive intake increased to 16%. Inclusion of DFS, FR and IFA together increased risk of excess iron intake to 40%. Nevertheless, intakes of folate and B 12 remained inadequate even with FR and/or IFA. These results indicate a high risk of dietary MNDs in children and suggest need for more systematic intake measurements in representative sample and adjustment of iron dosages to avoid excessive intakes., (© 2020 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.)

The development of photo-polymerizable ferrous sulfate liposomes has been perused for iron fortification of food. Iron fortification is accompanied by several limitations that reduce its quality as it provokes sensory problems due to the oxidation of Fe 2+ into Fe 3+ . To overcome such undesirable effects and improve the bioavailability of iron, photo-polymerizable 1,2-bis(10,12-tricosadiynoyl)-sn-glycero-3-phosphocholine (DC 8,9 PC) phospholipids have been employed as iron delivery system. DC 8,9 PC possesses diacetylene groups that undergo intramolecular cross-linking following UV treatment, resulting in enhanced stability, high encapsulation efficiency (~91%) without inducing sensory changes during milk fortification, along with less oxidation and con-tent leakage after long term storage in ethanol. Furthermore, polymeric Fe-DC 8,9 PC liposomes present high in vivo iron bioavailability in hemoglobin (Hb)-repletion study in rats, with no indications of toxicity examined by hematoxylin-eosin test. This methodology offers great promise for a simple, reliable, cost-effective, and robust platform for treating iron deficiency anemia, seeking to bring its application toward market., (Copyright © 2020 Elsevier Inc. All rights reserved.)

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.

In 1999, the National Food Consumption Survey found serious risk of dietary deficiency for a number of micronutrients in 1- to 9-year-old children in South Africa. To address these shortfalls, fortification with vitamin A, thiamine, riboflavin, niacin, vitamin B6, folic acid, iron and zinc of maize meal and bread flour was made mandatory in 2003. The aim of this study was to examine micronutrient intakes of 1- to <10-year-old children after nearly 20 years of fortification in two of the most urbanized and economically active provinces, Gauteng (GTG) and the Western Cape (WC). A multistage stratified cluster random sampling design and methodology was used. Households were visited by fieldworkers who interviewed caregivers and obtained dietary intake data by means of a multiple-pass 24-h recall. Two additional 24-h recalls were completed among a nested sample of 146 participants to adjust the single 24-h recall data of the total sample using the National Cancer Institute Method. Results show that median intake of all the fortification nutrients were above the estimated average requirement (EAR), with the only concern being folate in the WC. Between a quarter and a third of children in the WC, where maize porridge intake was significantly lower than in GTG, had a folate intake below the EAR. Nutrients that are not included in the fortification mix that remain a serious concern are calcium and vitamin D, with intake of dairy and vitamin D sources being very limited in both provinces. The improvement in micronutrient intakes of children is encouraging, however the outstanding nutrient deficiency risks need attention.

The article provides an overview of official documents and scientific literature on the development of a policy of enrichment of vitamins and minerals with diets of the population at the level of international organizations in various countries and in the world as a whole. International programs on micronutrient fortification of food products are considered from the standpoint of protecting public health. The article focuses on the availability and effectiveness of ways to improve the vitamin and mineral status of various social groups.

Objectives: The aim of this study was to determine the best foods for potential vitamin D food fortification and to model the efficacy and safety of different food fortification scenarios in adults ≥50 y of age in Ireland., Methods: National Adult Nutrition Survey vitamin D data for participants ≥50 y of age were updated. Vitamin D from foods with natural and added vitamin D was estimated and daily vitamin D intake patterns were examined. Data modeling was used to estimate the effects of target food fortification scenarios., Results: Almost two-thirds of the mean daily vitamin D intake of adults ≥50 y of age (7 ± 7 µg) comes from foods with added vitamin D. Milk and bread are the most frequently consumed foods across all meals and were subsequently targeted for the data modeling exercise. Results from the data modeling show that vitamin D intake increased between 9 and 17 µg/d, depending on the fortification scenario. Fortifying milk or bread resulted in ∼30% or ∼55% of individuals meeting the Recommended Daily Allowance (RDA); however, fortifying both simultaneously resulted in ∼70% meeting the RDA., Conclusions: Currently, the majority of Irish adults ≥50 y of age are not meeting dietary recommendations for vitamin D. Fortification of commonly consumed foods such as milk and bread could improve daily intakes such that ∼70% of the cohort would meet the minimum recommendation. Future research should examine the efficacy of different food fortification scenarios to improve vitamin D intakes for older adults., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Vitamin D (vitD) deficiency is a global childhood health problem. Food fortification is a promising strategy to curb vitD deficiency. We aimed to assess the effectiveness of utilizing vitD fortification in staple foods to improve 25hydroxyvitamin D (25(OH)D) concentration and to reduce the prevalence of vitD deficiency among healthy children., Methods: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) evaluating the use of vitD fortified food products compared to no fortification among healthy children aged 1-18 years old. We searched Medline, Embase, Global Health, and Cochrane (CENTRAL) databases from database inception until May 2019. Independently, six reviewers in pairs screened titles and abstracts, assessed the full text for eligibility, and performed data extraction and quality assessment. The primary outcome is the impact of fortification on 25(OH)D concentration. The secondary outcomes included the impact of fortification on the prevalence of vitD deficiency, school performance, cognitive function, school absences, infection rate, hospital admission length, and compliance with fortified food product consumption., Results: We identified 2229 articles. After assessing eligibility, 20 RCTs met the inclusion criteria. The eligible RCTs assessed the fortification of milk, cereal, juice, bread, yogurt, and cheese compared with no fortification. All RCTs, except for three, had a low risk of bias. Food fortification improved 25(OH)D concentration by a mean difference (MD) of 15.51 nmol/L (95% confidence interval (CI) 6.28, 24.74; I 2 = 99%), which resulted in a mean increase of 3 nmol/l for every 100 IU of vitD, when adjusted for baseline 25(OH)D concentration and country latitude. Additionally, the prevalence of vitD deficiency decreased by a risk ratio of 0.53 (95% CI 0.41, 0.69; I 2 = 95%), and cognitive function improved by a MD of 1.22 intelligence quotient (IQ) points (95% CI 0.65, 1.79; I 2 = 0%). The overall evidence quality was high., Conclusion: VitD food fortification is an effective way to improve 25(OH)D concentration, prevent vitD deficiency, and improve IQ levels., Systematic Review Registration: PROSPERO CRD42017057631.

Food fortification is used as a nutrition support strategy in aged care homes, for residents who are malnourished or at risk of malnutrition. The aim of this review was to determine the scope and strength of published works exploring relationships between food fortification strategies, mode of delivery and sustainability in aged care homes. Literature from four databases and grey literature was searched. A total of 3152 articles were screened. Seventeen studies were included. Results showed that the majority of studies used pre-made food fortification, rather than fortifying foods on-site. There was heterogeneity across studies, including the mode of delivery and ingredients used for food fortification. Only two studies measured any aspect of costs. No clear sustainable strategies for implementing food fortification in this setting could be identified. Research is required to provide further insight into the acceptability and sustainability of food fortification interventions.

Background: 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., Objective: To determine whether fortified rice (proposed) and fortified wheat flour potentially benefit women of reproductive age (WRA)., Methods: 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., Results: 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., Conclusions: 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.

Objective: To simulate effects of different scenarios of folic acid fortification of food on dietary folate equivalents (DFE) intake in an ethnically diverse sample of pregnant women., Design: A forty-four-item FFQ was used to evaluate dietary intake of the population. DFE intakes were estimated for different scenarios of food fortification with folic acid: (i) voluntary fortification; (ii) increased voluntary fortification; (iii) simulated bread mandatory fortification; and (iv) simulated grains-and-rice mandatory fortification., Setting: Ethnically and socio-economically diverse cohort of pregnant women in New Zealand.ParticipantsPregnant women (n 5664) whose children were born in 2009-2010., Results: Participants identified their ethnicity as European (56·0 %), Asian (14·2 %), Māori (13·2 %), Pacific (12·8 %) or Others (3·8 %). Bread, breakfast cereals and yeast spread were main food sources of DFE in the two voluntary fortification scenarios. However, for Asian women, green leafy vegetables, bread and breakfast cereals were main contributors of DFE in these scenarios. In descending order, proportions of different ethnic groups in the lowest tertile of DFE intake for the four fortification scenarios were: Asian (39-60 %), Others (41-44 %), European (31-37 %), Pacific (23-26 %) and Māori (23-27 %). In comparisons within each ethnic group across scenarios of food fortification with folic acid, differences were observed only with DFE intake higher in the simulated grains-and-rice mandatory fortification v. other scenarios., Conclusions: If grain and rice fortification with folic acid was mandatory in New Zealand, DFE intakes would be more evenly distributed among pregnant women of different ethnicities, potentially reducing ethnic group differences in risk of lower folate intakes.

Objective: To assess the median urine iodine concentration (UIC) of young adults in the Top End of Northern Territory, before and after fortification of bread with iodised salt became mandatory., Design, Setting: Analysis of cross-sectional data from two longitudinal studies, the Aboriginal Birth Cohort and the non-Indigenous Top End Cohort, pre- (Indigenous participants: 2006-2007; non-Indigenous participants: 2007-2009) and post-fortification (2013-15)., Participants: Indigenous and non-Indigenous Australian young adults (mean age: pre-fortification, 17.9 years (standard deviation [SD], 1.20 years); post-fortification, 24.9 years (SD, 1.34 years)., Main Outcome Measure: Median UIC (spot urine samples analysed by a reference laboratory), by Indigenous status, remoteness of residence, and sex., Results: Among the 368 participants assessed both pre- and post-fortification, the median UIC increased from 58 μg/L (interquartile range [IQR], 35-83 μg/L) pre-fortification to 101 μg/L (IQR, 66-163 μg/L) post-fortification (P < 0.001). Urban Indigenous (median IUC, 127 μg/L; IQR, 94-203 μg/L) and non-Indigenous adults (117 μg/L; IQR, 65-160 μg/L) were both iodine-replete post-fortification. The median UIC of remote Indigenous residents increased from 53 μg/L (IQR, 28-75 μg/L) to 94 μg/L (IQR, 63-152 μg/L; p < 0.001); that is, still mildly iodine-deficient. The pre-fortification median UIC for 22 pregnant women was 48 μg/L (IQR, 36-67 μg/L), the post-fortification median UIC for 24 pregnant women 93 μg/L (IQR, 62-171 μg/L); both values were considerably lower than the recommended minimum of 150 μg/L for pregnant women., Conclusions: The median UIC of young NT adults increased following mandatory fortification of bread with iodised salt. The median UIC of pregnant Indigenous women in remote locations, however, remains low, and targeted interventions are needed to ensure healthy fetal development., (© 2018 AMPCo Pty Ltd.)

Iron deficiency is the most common form of malnutrition. Factors responsible for this so-called "hidden hunger" include poor diet, increased micronutrient needs and health problems such as diseases and infections. Body iron status can be increased by the intake of dietary supplements and fortified food. The aim of the present study was to compare iron bioaccessibility from commercial nutritional supplements and iron microcapsules. A comparison study was performed under conditions mimicking gastric and gastrointestinal digestion. A preparation of encapsulated ferrous sulphate or lactate and vitamin C, in a formula, showed bioaccessibility factors of up to 100% when digested individually, and around 60% in the presence of a food matrix. The degree of oxidation of the ferrous ions differed, depending on the type of preparation, the presence of vitamin C and the food matrix. The highest percentage content of ferrous ion, in the soluble fractions after gastrointestinal digestion, was shown by the preparation containing microencapsulated ferrous lactate or ferrous sulphate and vitamin C. Encapsulation seems to limit the interaction of iron with the food matrix and protect it against oxidation, thus making it more accessible for intestinal uptake.

This study assessed awareness and attitudes regarding industrial food fortification among adults in urban and rural Mongolia, and the city of Harbin, China. Between 2014 and 2017, surveys were collected from healthy men and women aged ≥18 years (182 Harbin residents and 129 urban and rural Mongolians participating in a nationwide nutrition survey in Mongolia). Survey reproducibility was assessed among 69 Mongolian participants to whom it was administered twice (summer and winter). Findings revealed that only 19% of rural and 30% of urban Mongolians, and 48% of Harbin residents were aware that industrial fortification is practiced in their countries. For most food groups evaluated, at least half of Mongolians and less than half of Harbin residents thought fortification was government-mandated (only the addition of iodine with salt is actually mandated in both countries). Fifty-five percent of rural and urban Mongolians favored mandatory fortification of foods, 14% disapproved of it, and 31% were uncertain (compared with 25%, 38%, and 37% respectively in Harbin). Upon learning that the primary purpose of adding vitamin D to milk is to prevent rickets, 75% of Mongolians but only 18% of Harbin residents favored mandatory fortification, while 42% of Harbin residents favored voluntary fortification (compared with <10% of Mongolians). In conclusion, in Mongolia and Harbin, awareness and understanding of food fortification is low, as is receptivity toward mandatory fortification. Health promotion and social marketing should be designed to create an enabling environment for increasing supply and demand of fortified foods, in support of upcoming program implementation in Mongolia and potential future legislation in northeern China.

Background: Salt fortification with iron is a potential strategy to increase population-level iron intake. The current evidence regarding double-fortified salt (DFS) in improving iron nutrition status is equivocal., Objective: To study the efficacy of DFS as compared to iodine fortified salt (IS) in improving iron nutrition status., Methods: Randomized controlled trials comparing DFS and IS until August 2016 were systematically searched across multiple databases to assess for change in mean hemoglobin (Hb), prevalence of anemia, iron deficiency (ID), ID anemia (IDA), serum ferritin, and serum transferrin receptor (TfR). Meta-analysis was performed using R software., Results: Of the initial 215 articles retrieved using the predetermined search strategy, data from 10 comparisons of DFS and IS across 8 randomized controlled trials are included. There was significant heterogeneity across included studies and the studies were of low to very low quality as per GRADE criteria. DFS significantly increased mean Hb by 0.44 g/dl (95% confidence interval [CI]: 0.16, 0.71) and significantly decreased anemia (risk difference -0.16; 95% CI: -0.26, -0.06) and ID (risk difference -0.20; 95% CI: -0.32, -0.08) as compared to IS. There was no statistically significant difference in change in ferritin levels (mean difference 0.62 μg/L; 95% CI: -0.12, 1.37), serum TfR levels (mean difference -0.23 mg/dL; 95% CI: -0.85, 0.38), and IDA (risk difference -0.08; 95% CI: -0.28, 0.11)., Conclusion: DFS is a potentially efficacious strategy of addressing anemia as a public health problem at population level. There is a need for effectiveness trials before DFS can be scaled up in program mode at population level., Competing Interests: None

Vitamin D is essential for bone health and has significant roles in non-skeletal health and organ function. Dermal synthesis through exposure to ultraviolet B light is the major natural source of vitamin D, while only a small portion of the necessary amount can be acquired by a diet without fortified foods. In recent years, vitamin D deficiency as a result of lifestyles with inadequate sun exposure, has received increased attention due to its association with the increased risk of serious chronic diseases. This review summarizes our current understanding of food fortification strategies with vitamin D and the resulting health impact. Conventional and biotechnological approaches can be used for the production of new and novel vitamin D rich or vitamin D fortified foods. The availability of a wider range of every-day consumed fortified foods as part of a "Daily D" public health policy can contribute to the improvement of vitamin D status and to prevention of vitamin D deficiency., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Food-based solutions for optimal vitamin D nutrition and health through the life cycle (ODIN) was a cross-disciplinary, collaborative project, including 30 partners from 19 countries, which aimed to develop evidence-based solutions to prevent low vitamin D status (25-hydroxyvitamin D (25(OH)D) < 30 nmol/L) using a food-first approach. This paper provides a summary overview of some of the important ODIN outcomes and outlines some outstanding data requirements. In a study of almost 56,000 individuals, the first internationally standardised dataset of vitamin D status showed that 13% of EU residents overall, across a latitude gradient of 35° N to 69° N, had serum 25(OH)D < 30 nmol/L and 40% were < 50 nmol/L. The risk of low vitamin D status was several-fold higher among persons of ethnic minority. However, additional data from quality bio-banked sera would be required to improve these estimates. To address the question of dietary requirements for vitamin D among under-researched life-stage and population groups, four dose-response RCTs conducted in Northern Europe showed that vitamin D₃ intakes of 8 and 13 μg/day prevented 25(OH)D decreasing below 30 nmol/L in white children and adolescents and 20 and 30 μg/day, respectively, achieved ≥50 nmol/L. Among white women during pregnancy, 30 μg/day is required to prevent umbilical cord 25(OH)D, representing new-born vitamin D status, below 25 nmol/L. While 8 μg/day protected white women in Finland at the 30 nmol/L cut-off, 18 μg/day was needed by women of East African descent to prevent 25(OH)D decreasing below 30 nmol/L during wintertime. Replicate RCTs are needed in young children <5 years and in school-age children, teens and pregnant women of ethnic minority. Using a series of food production studies, food-based RCTs and dietary modelling experiments, ODIN research shows that diverse fortification strategies could safely increase population intakes and prevent low vitamin D status. Building on this solid technological platform, implementation research is now warranted to scale up interventions in real-world settings to eradicate vitamin D deficiency.

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.

Within Europe, dark-skinned ethnic groups have been shown to be at much increased risk of vitamin D deficiency compared to their white counterparts. Increasing the dietary supply of vitamin D is potentially the only modifiable environmental component that can be used to prevent vitamin D deficiency among dark-skinned ethnic groups living at high latitude. Empirical data to support development of such strategies is largely lacking. This paper presents the development and validation of an integrated model that may be adapted within the UK population to design fortification strategies for vitamin D, for application in both white and black and Asian minority ethnic (BAME) population groups. Using a step-wise approach, models based on available ultraviolet B (UVB) data, hours of sunlight and two key components (the dose-response of serum 25-hydroxyvitamin D [25(OH)D] to UVB in white and BAME persons and the dose-response of 25(OH)D to vitamin D) were used to predict changes population serum 25(OH)D concentrations throughout the year, stratified by ethnicity, 'via increases' in dietary intake arising from food fortification simulations. The integrated model successfully predicted measured average wintertime 25(OH)D concentrations in addition to the prevalence of serum 25(OH)D <30nmol/L in adult white and BAME individuals (18-70y) in the UK-based National Diet and Nutrition Survey both separately (21.7% and 49.3% predicted versus 20.2% and 50.5% measured, for white and BAME, respectively) and when combined at UK population-relevant proportions of 97% white and 7% BAME (23.2% predicted versus 23.1% measured). Thus this integrated model presents a viable approach to estimating changes in the population concentrations of 25(OH)D that may arise from various dietary fortification approaches., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

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.

Young children are at risk of iron deficiency and subsequent anaemia, resulting in long-term consequences for cognitive, motor and behavioural development. This study aimed to describe the iron intakes, status and determinants of status in 2-year-old children. Data were collected prospectively in the mother-child Cork BASELINE Birth Cohort Study from 15 weeks' gestation throughout early childhood. At the 24-month assessment, serum ferritin, haemoglobin and mean corpuscular volume were measured, and food/nutrient intake data were collected using a 2-day weighed food diary. Iron status was assessed in 729 children (median [IQR] age: 2.1 [2.1, 2.2] years) and 468 completed a food diary. From the food diary, mean (SD) iron intakes were 6.8 (2.6) mg/day and 30% had intakes < UK Estimated Average Requirement (5.3 mg/day). Using WHO definitions, iron deficiency was observed in 4.6% (n = 31) and iron deficiency anaemia in five children (1.0%). Following an iron series workup, five more children were diagnosed with iron deficiency anaemia. Twenty-one per cent had ferritin concentrations <15 µg/L. Inadequate iron intakes (OR [95% CI]: 1.94 [1.09, 3.48]) and unmodified cows' milk intakes ≥ 400 mL/day (1.95 [1.07, 3.56]) increased the risk of low iron status. Iron-fortified formula consumption was associated with decreased risk (0.21 [0.11, 0.41] P < 0.05). In this, the largest study in toddlers in Europe, a lower prevalence of low iron status was observed than in previous reports. Compliance with dietary recommendations to limit cows' milk intakes in young children and consumption of iron-fortified products appears to have contributed to improved iron status at two years., (© 2016 John Wiley & Sons Ltd.)

Objective: The study evaluates the economic benefit of population-wide vitamin D and Ca food fortification in Germany., Design: Based on a spreadsheet model, we compared the cost of a population-wide vitamin D and Ca food-fortification programme with the potential cost savings from prevented fractures in the German female population aged 65 years and older., Setting: The annual burden of disease and the intervention cost were assessed for two scenarios: (i) no food fortification; and (ii) voluntary food fortification with 20 µg (800 IU) of cholecalciferol (vitamin D3) and 200 mg of Ca. The analysis considered six types of fractures: hip, clinical vertebral, humerus, wrist, other femur and pelvis., Subjects: Subgroups of the German population defined by age and sex., Results: The implementation of a vitamin D and Ca food-fortification programme in Germany would lead to annual net cost savings of €315 million and prevention of 36 705 fractures in the target population., Conclusions: Vitamin D and Ca food fortification is an economically beneficial preventive health strategy that has the potential to reduce the future health burden of osteoporotic fractures in Germany. The implementation of a vitamin D and Ca food-fortification programme should be a high priority for German health policy makers because it offers substantial cost-saving potential for the German health and social care systems.

Nanotechnology offers new opportunities for providing health benefits in foods. Food fortification with iron phosphate nanoparticles (FePO 4 NPs) is a promising new approach to reducing iron deficiency because FePO 4 NPs combine high bioavailability with superior sensory performance in difficult to fortify foods. However, their safety remains largely untested. We fed rats for 90 days diets containing FePO 4 NPs at doses at which iron sulfate (FeSO 4 ), a commonly used food fortificant, has been shown to induce adverse effects. Feeding did not result in signs of toxicity, including oxidative stress, organ damage, excess iron accumulation in organs or histological changes. These safety data were corroborated by evidence that NPs were taken up by human gastrointestinal cell lines without reducing cell viability or inducing oxidative stress. Our findings suggest FePO 4 NPs appear to be as safe for ingestion as FeSO 4 .

Rice fortification offers great potential to deliver essential micronutrients to a large part of the world population. However, high temperatures required for cooking rice are deleterious to thermally labile micronutrients. This study evaluated the content and stability of thiamin and folic acid in fortified rice after different cooking methods (stir-frying, boiling, cooking in a microwave oven and boiling in a Food Service). The analyses were performed by High Performance Liquid Chromatography (HPLC). The fortified rice showed the highest thiamin content (0.97 mg/kg) and retention (65.4%) when cooked in microwave oven, and for folic acid the lowest content (0.17 mg/kg) and the highest retention (96.11%) when cooked in a Food Service and stir-fried, respectively. In conclusion, the stability of thiamin and folic acid varied according to the cooking method and the stability of folic acid presented higher percentages in relation to thiamin in the different methods. [Formula: see text].

In light of evidence that high-dose iron supplements lead to a range of adverse events in low-income settings, the safety and efficacy of lower doses of iron provided through biological or industrial fortification of foodstuffs is reviewed. First, strategies for point-of-manufacture chemical fortification are compared with biofortification achieved through plant breeding. Recent insights into the mechanisms of human iron absorption and regulation, the mechanisms by which iron can promote malaria and bacterial infections, and the role of iron in modifying the gut microbiota are summarized. There is strong evidence that supplemental iron given in nonphysiological amounts can increase the risk of bacterial and protozoal infections (especially malaria), but the use of lower quantities of iron provided within a food matrix, ie, fortified food, should be safer in most cases and represents a more logical strategy for a sustained reduction of the risk of deficiency by providing the best balance of risk and benefits. Further research into iron compounds that would minimize the availability of unabsorbed iron to the gut microbiota is warranted., (© The Author(s) 2016. Published by Oxford University Press on behalf of the International Life Sciences Institute.)

Unlabelled: Dietary supplements are a multi-billion dollar industry in the U.S., and their use is increasing exponentially. Additionally, many foods and beverages are increasingly being fortified with single or multiple vitamins and minerals. Consequently, nutrient intakes are exceeding the safe limits established by the Institute of Medicine. In this paper, we examine the benefits and drawbacks of vitamin and mineral supplements and increasing consumption of fortified foods (in addition to dietary intake) in the U.S., Population: The pros and cons are illustrated using population estimates of folic acid, calcium, and vitamin D intake, highlighting concerns related to overconsumption of nutrients that should be addressed by regulatory agencies.