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Food Fortification in Public Health Policy


Food Fortification in Public Health Policy TH Tulchinsky MD MPH Braun SPH 2 Nov 2004 Public Health Nutrition Strategies Food based strategy Socio economic factors ... – PowerPoint PPT presentation

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Title: Food Fortification in Public Health Policy

Food Fortification in Public Health Policy
  • TH Tulchinsky MD MPH
  • Braun SPH
  • 2 Nov 2004

Essential Considerations
  • Public health and medical responsibility
  • Food industry and regulators involved
  • Create demand - enriched foods, behavior changes
  • Monitor compliance and ID rates
  • National council on nutrition - academic and
    professional organizations and public reps
  • Long term program
  • Regulatory, monitoring and laboratory support

Public Health Nutrition Strategies
  • Food based strategy
  • Socio economic factors
  • Food supply/costs
  • Supplementation for target groups
  • Women and children
  • Elderly
  • Fortification of basic foods
  • Surveillance and monitoring
  • Education
  • Public
  • Professional

18-19th Century Breakthroughs
  • Lind and scurvy 1747
  • Lemon juice in Royal Navy, 1796
  • Davy isolates sodium, potassium, calcium,
    magnesium, sulphur, boron, 1807
  • Chatin shows iodine prevents goiter, 1850
  • Takaki and beriberi, Japanese Navy, 1885
  • Eijkman publishes cause of beriberi, 1897

Vital Amines
  • 1900, nutrition - calories, fats, carbohydrates
  • 1912, Funk defines vital amines
  • Rickets, scurvy, goiter, beriberi common in
    industrial countries
  • Pellagra epidemic in southern US
  • 1914, Goldberger of USPHS investigates pellagra
  • 1922, McCollum and vitamin D in cod liver oil

Key Landmarks
  • Mortons iodized salt, 1924
  • Louisiana - mandates vit B fortification of
    flour, 1928
  • US federal mandate - enrichment of flour with
    vitamins B and iron, 1941
  • UK and colonies same during WWII

Preventing Goiter and Iodine Deficiency Disorders
  • 1917, high US draftees rejected - goiter
  • 1922-27, goiter rates fall from 39 to 9 by
    statewide prevention programs
  • 1924, Mortons Iodized Salt (N America)
  • 1979, Iodization mandatory in Canada
  • 1980s, WHO - universal iodization of salt
  • Many countries achieved iodization

Iodine Fortification of Salt in the U.S.
Trend in Goiter Prevalence in Michigan
WHO Monograph Series N. 44
Pellagra The 4 Ds
  • Diarrhea, dermatitis, dementia, death
  • Thought to be of infectious origin
  • Common in prisons, mental institutions,
    sharecroppers in southern US
  • Curable by dietary change (Goldberger)
  • 1929, niacin found as essential factor
  • 1906-1940, 3 million cases and 100,000 deaths
    attributed to pellagra

Figure 2                                       
  • 1921, rickets affects 75 of children in New York
    City schools
  • Cod liver oil commonly used (middle class)
  • 1940s, US fortifies milk with vitamin D
    dramatically reduces rickets incidence
  • Canada fortifies milk 1940s, then refortifies
    resulting in increase in rickets in 1960s

Low Cost Solutions to Eliminate Micronutrient
Annual Per Capita Cost of Interventions
Source World Bank, 1994
Relative Cost Effectiveness of Micronutrient
Source UNICEF/UNU/WHO/MI, 1999
Iron Deficiency
  • Commonest MND
  • Affects survival, health and productivity
  • Affects women in age of fertility
  • Affects pregnancy and newborn
  • Affects growth and cognitive development of
    infants and children
  • Interaction with vitamin C deficiency

Global Burden of Iron Deficiency
WHO Region Anemic or Iron Deficient Prevalence of Anemia in Pregnancy
Africa America Europe E. Mediterranean S.E. Asia Western Pacific 206 94 27 149 616 1058 52 60 18 50 74 40
  • Source WHO

Benefits of PreventingIron Deficiency
  • Benefits to children
  • Improved behavioral and cognitive development
  • Improved child survival (where severe anemia is
  • Benefits to adolescents
  • Improved cognitive performance
  • Better iron stores for later pregnancies (females)

  • Benefits to Pregnant Women and Their Infants
  • Decreased low birth weight and perinatal
  • Decreased maternal mortality and obstetrical
    complications (where severe anemia is common)
  • Benefits to all Individuals
  • Improved fitness and work capacity
  • Improved cognition
  • Increased immunity
  • Lower morbidity from infectious disease

Trends in Prevalence of Anemia in Low-income
U.S. Children, 12-17 Months Old
Hgb lt10.3 g/dL Yip et al., JAMA, 1987
  • Preschool children
  • School age children
  • and adolescents
  • Non-pregnant women
  • Pregnant women
  • Adult men

Prevalence of iron deficiency by income and
race/ethnicity, U.S., 1-4 year olds, 1988-94
Based on serum ferritin model NHANES III (Ogden
et al., 1998)
US Federal Policy
  • USDA extension programs
  • 1921-29, US Maternal and Infancy Act - state
    health departments employ nutritionists
  • 1930s, relief/commodity distribution
  • 1941, enriched wheat flour with iron, vit B
  • 1941, US establishes RDAs
  • Food stamps, WIC, school lunch programs
  • National nutrition surveys

Canada 1979
  • National nutrition survey 1971
  • Geographic, social and ethnic deficiencies
  • Process of consultation
  • 1979 federal regulations, mandatory
  • Vitamin A and D in all milk products
  • Iodine in salt
  • Vitamins B and iron in flour

Epidemiologic Revolution 1960s-1980s
  • Risk factors for chronic disease
  • Health field concept
  • Health for All
  • Declining mortality from stroke and CHD, trauma
  • Advances in drugs and diagnostics
  • Control of infectious diseases
  • Rapid increase in costs of care health system

Nutrition Interactions
  • Iodine Deficiency psychomotor retardation
  • Iron Def Anemia and infectious diseases
  • Iron promotes growth and development
  • Vitamin A and infectious diseases e.g. measles
  • Vitamin A promotes growth
  • Folic acid prevents birth defects
  • Folic acid with CVD, Alzheimers Disease
  • Nutrition and cancer
  • Nutrition and cardiovascular disease
  • Nutrition and diabetes
  • Nutrition in disease management

Folic Acid and NTDs
  • Pre pregnancy folic acid supplements prevent
    neural tube defects, 1980s
  • Supplements to women in age of fertility achieves
    lt1/3 coverage, 1990s (US)
  • FDA mandates fortification of enriched flour,
    from 1998
  • Canada and UK also mandate folic acid
    fortification of flour
  • New paradigm in public health

Table Return to top. Figure
Global prevention of all folic acid-preventable
spina bifida and anencephaly by 2010. Oakley GP.
Community Genet. 2002 Sep5(1)70-7.
  • Spina bifida and anencephaly are pandemic,
    affecting 225,000 children a year.
  • Need commitment to global prevention of all folic
    acid-preventable spina bifida and anencephaly
    (FA-P SBA) by 2010.
  • Folic acid fortification of centrally processed
    foods, such as wheat and corn flour, could
    immediately prevent all of these birth defects
    for much of the world's population.
  • Fortification programs also help adults by
    increasing serum folate concentration,
    eradicating folate deficiency anemia, provide
    human genome stability and reduce homocysteine
    serum levels.
  • Probably prevent heart attacks and strokes, and
    may prevent colon cancer and Alzheimer's disease.

Folic Acid Supplements and Fortification Affect
the Risk for Neural Tube Defects, Vascular
Disease and Cancer Evolving Science.
  • Folic acid supplements reduce the risk of NTDs
    and may be associated with reduced risk for
    vascular disease and cancer.
  • Observational and controlled intervention studies
    support public health policies related to folic
    acid and NTDs.
  • Educational to promote daily intake of FA
    supplements by women of reproductive age did not
    increase supplement use.
  • Food fortification appears to be associated with
    a reduction in neural tube defects in the United
    States and Canada
  • Potential for FA supplements to reduce the
    incidence, severity of vascular disease and
    cancer is focus of major research including
    intervention studies.

Bailey LB et al. J. Nutr. 1331961S-1968S, 2003.
Food Fortification Cuts Cases of Spina Bifida in
  • Fortification of food with folic acid
    dramatically reduces the incidence of spina
    bifida and other NTDs, without masking vitamin
    B-12 deficiency in elderly people..
  • Canadian study in Newfoundland, an area with
    historically high rates of neural tube defects
    showed 78 reduction after fortification..
  • In 1998 fortification of white flour, pasta, and
    cornmeal with folic acid was imposed in Canada to
    increase the intake of folic acid of all women of
    childbearing age..
  • NTD rates fell from 4.36/1000 births before
    fortification to 0.96 in 1000 births after

BMJ Oct 2004
American Academy of PediatricsCommittee on
  • The AAP endorses the US Public Health Service
    recommendation that all women capable of becoming
    pregnant consume 400 µg of folic acid daily to
    prevent neural tube defects (NTDs).
  • Studies show periconceptional folic acid
    supplementation prevents 50 or more of NTDs e.g.
    spina bifida, anencephaly.
  • Implementation of these recommendations is
    essential for the primary prevention of these
    serious, disabling birth defects.
  • Because fewer than 1 in 3 women consume amount of
    folic acid recommended by the USPHS, the AAP
    notes prevention of NTDs depends on an urgent and
    effective campaign to close this prevention gap.
  • Pediatrics104,
  • August 1999 325-7

Plasma Homocysteine as a Risk Factor for Dementia
and Alzheimer's Disease.
  • Elevated plasma homocysteine levels associated
    with poor cognition, dementia. A total of 1092
    subjects without dementia (667 women and 425 men
    (mean age, 76 years) from the Framingham Study
    study sample.
  • Examined the relation of the plasma total
    homocysteine level measured at base line and
    eight years earlier.
  • Over period of eight years, dementia developed in
    111 subjects, including 83 with Alzheimer's
  • Multivariable-adjusted RR of dementia was 1.4 (CI
    1.1 to 1.9) for each increase of 1 SD in the
    homocysteine value at base line or eight years
  • The RR of Alzheimer's disease was 1.8 (CI-1.3 to
    2.5) per increase of 1 SD at base line and 1.6
    (CI 1.2- 2.1) per increase of 1 SD eight years
    before base line. With a plasma homocysteine
    level greater than 14 µmol per liter, the risk of
    Alzheimer's disease nearly doubled.
  • Increased plasma homocysteine level is a strong,
    independent risk factor for the development of
    dementia and Alzheimer's disease.

Seshadri S, Beiser A, Selhub J, et al. NEJM.
3467476-483, 2003
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Folic Acid and Heart Disease
  • High homocysteine levels associated with excess
    CHD, birth defects, Alzheimers Disease
  • Folic acid reduces high homocysteine
  • Flour fortification effective in raising FA
    levels in population
  • Clinical trials of folic acid and CHD underway
  • New paradigm in public health nutrition

  • Aging of the population
  • Vit D production in skin seasonal
  • Sun varies by season and latitude even in sunny
  • Fortification of calcium popularized
  • Vitamin D lacking in raw milk
  • Calcium, vitamin D, fluoride co-factors
  • Fortifying milk products with Vit D needed

Fortification strategies to meet micronutrient
  • Food fortification played important role in the
    nutritional health, well-being of populations in
    industrial countries.
  • From early 20th C, fortification targeted
    specific conditions goitre with iodized salt
    rickets with vitamin D-fortified milk beriberi,
    pellagra and anaemia with B-vitamins and
    Fe-enriched cereals.
  • Recently, in the US, risk of pregnancy affected
    by NTDs with folic acid-fortified cereals.
  • Enormous increase in fortification programs in
    developing countries, in reducing vitamin A and I
    deficiencies, but less so with Fe.
  • Food fortification can play an large role in
    prevention and control of micronutrient

Proc Nutr Soc. 2002 May61(2)231-41
Problems with Fortification Policy
  • Antagonism to North American initiatives
  • European resistance e.g. EU
  • Nutritionist focus on clinical approach
  • WHO ambivalence/opposition
  • Green attitudes
  • Medical attitudes and lack of interest
  • Resistance to mandatory medication
  • Individual choice vs. public good
  • Clinical vs. population approaches
  • Manufacturers and regulatory agency attitudes

  • Decreased contamination and food-borne disease
  • Improved food handling methods - refrigeration
  • Improved nutritional value of foods and crops
  • Food fortification
  • Identifying essential micronutrients
  • Food-fortification programs eliminated rickets,
    goiter, pellagra in the US, Canada
  • Folic acid and other new disease relationships
  • Micronutrients as functional food elements
  • Genetically engineered foods

Folic acid fortification of wheat flour Chile.
  • Neural tube defects (open spina bifida,
    anencephaly, and encephalocele) represent the
    first congenital malformations to be preventable
    through public health measures such as
    supplementation and/or food fortification with
    folic acid.
  • In Chile, starting in January 2000, the Chilean
    Ministry of Health legislated to add folic acid
    to wheat flour (2.2 mg/kg) to reduce the risk of
  • This policy resulted in an estimated mean
    additional supply of 427 microg/d in significant
    increases in serum folate and red cell folate of
    3.8 and 2.4-fold, respectively, in women of
    fertile age, one year after fortification.
  • The impact on the rate of NTDs is presently being
    studied in all births, both live births and still
    births, with birth weight gt500 g in the city of
    Santiago. Preliminary results show a reduction of
    40 in the rates on NTDs from the
    pre-fortification period (1999-2000) to
    post-fortification period (2001-June 2002).
    Fortification of wheat flour with folic acid in
    Chile is effective in preventing NTDs in Chile.

Nutr Rev. 2004 Jun62S44-8
Changes in NTD prevalence rates after folic acid
fortification in South America
  • Several South American countries are fortifying
    wheat flour with folic acid. Chile started in
    2000 to add 2.2 mg/kg, providing 360 mcg daily
    per capita.
  • Data from 361,374 births occurred in 43 South
    American hospitals, in five countries, in
  • Chile, showed decrease of 31 during the
    2000-2001. Significance (P lt 0.001) reached in
    the 20th month after fortification started.

Am J Med Genet. 2003 Dec 1123A123-128
Recent Findings in Israel
  • Berry Committee recommends fortification 1986
  • Process of implementation slow
  • Anemia rates declining but still high
  • Iodine deficiency Sack, Mates et
  • Folic acid low, homocysteine levels high, vit
    B12 levels low (Kark)
  • Voluntary fortification
  • Mandatory fortification of flour, salt and milk
    products regulations in progress

DMFT in Europe
  • Nutrition a major public health issue
  • Fortification is one of the key PH inteventions
  • Affects MCH, infectious, non infectious disease
  • High priority birth defects, IDA, IDD, CHD
  • Fortification has low sex appeal vs. clinical Rx
    or Px
  • Mandatory vs. voluntary false dilemma
  • Requires concern, knowledge, conviction,
    advocacy, persistence and leadership
  • Population health perspective
  • Public health role is to implement successful

Referent Agencies
  • World Health Organization
  • Centers for Disease Control
  • American Academy of Pediatrics
  • American College Obstetrics and Gynecology
  • US Food and Drug Administration
  • Health Canada
  • March of Dimes
  • World Bank
  • Micronutrient International and other NGOs
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