This document discusses food fortification as a public health policy to address micronutrient deficiencies. It outlines key issues like iodine, iron, and folic acid deficiencies and the diseases they cause. Food fortification is presented as a low-cost solution to eliminate micronutrient malnutrition. The document reviews the history of fortification for various nutrients and its impact on reducing related health issues. It examines individual country policies and the effect of mandatory fortification on improving public health outcomes.

1. Food Fortification as
Public Health Policy
TH Tulchinsky MD MPH
Braun SPH
24 November 2013
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2. 2

3. WHO,
FAO
2006
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4. Key Fortification issues
• Iodine – cretinism, Iodine deficiency disorders (IDD)
• Iron – iron deficincy and anemia
• Vitamin B complex (B1, B2, B3, B6, B9, B12)
• Vitamin D – rickets, osteoporosis, and linked with
many medical conditions
• Folic acid – pre pregnancy neural tube defects;
pregnancy macrocytic anemia
• Others – calcium, selenium, zinc
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5. 5

6. 6

7. 7

8. 8

9. 9

10. 10

11. Essential Considerations
 Micronutrient deficiency conditions widespread
 Non mandatory enriched foods are costly and not
available to the poor e.g. bread, milk, yoghurts, salt
 Public health and medical responsibility
 WHO and best practices standards
 Regulatory, monitoring and laboratory support are
governmental public health responsibilities
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12. Public Health Nutrition Strategies
• Education
• Food based strategy
– Socio economic factors
– Food supply/costs
– Education
• Supplementation for target groups
– Women and children
– Elderly
• Fortification of basic foods
• Surveillance and monitoring
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13. 18-19th Century Breakthroughs
• James Lind and scurvy 1747
• Lemon juice mandatory in Royal Navy, 1796
• Humphrey 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 (Nobel
Prize 1929, anti-neuritic vitamin)
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14. Vital Amines
• 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
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15. Key Landmarks
• Iodized salt, 1924
• Louisiana - mandates vit B fortification of
flour to control pellagra epidemic, 1928
• US federal mandate - enrichment of flour with
vitamins B and iron, 1941
• Britain and colonies same during WWII
• Canada mandates fortification in 1979
• Folic acid found to prevent NTDs in 1990s
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16. Iron
Suppl.
Iron Fort. Iodine
Suppl.
Iodine
Fort.
Vit A
Suppl.
Vit A
Fort.
U
.
S
.
Dollars
Low Cost Solutions to Eliminate
Micronutrient Malnutrition
Source: World Bank, 1994
Annual Per Capita Cost of Interventions
World Bank 1994 16

17. 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 Morton’s Iodized Salt (N America)
• 1979 Iodization mandatory in Canada
• 1980s WHO - universal iodization of salt
• Most member countries achieved iodization
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18. Iodine Fortification of Salt in the U.S.:
Trend in Goiter Prevalence in Michigan
Year
Percent
WHO Monograph
Series N. 44
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19. 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
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20. Figure 2
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21. Rickets Returns
• Past decade vast increase in publications
• Occurs in breast fed un-supplemented LBW
babies
• High risk for newborns of dark skinned or
totally covered women in northern latitudes, or
in winter-spring
• Low vitamin D levels found in all age groups in
Israel (KH Maccabee)
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22. Osteoporosis
• Aging of the population, women> men
• Vitamin D production in skin
• Sun varies by season and latitude even in
sunny countries
• Indoor occupations children and adults
• Fortification of calcium popularized
• Vitamin D lacking in raw milk
• Calcium, vitamin D, fluoride co-factors
• Fortifying milk products with Vit D needed
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23. 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
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24. Trends in Prevalence of Anemia* in Low-income
U.S. Children, 12-17 Months Old
Birth Year
Percent
Program Enrollment
Follow-up
*Hgb <10.3 g/dL
Yip et al., JAMA, 1987 24

25.  Preschool children
 School age
children
and adolescents
 Non-pregnant
women
 Pregnant women
 Adult men
1998
www.cdc.gov/mmwr
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26. 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
• Policy review 2005
• Folic acid mandatory since 1998
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27. Folic Acid and NTDs
• Pre pregnancy folic acid supplements prevent neural
tube defects, 1980s
• Supplements to women in age of fertility achieves
<1/3 coverage, 1990s (US)
• FDA mandates fortification of “enriched” flour, 1998
• Canada, Chile also mandate folic acid fortification of
flour from 1998
• Preliminary reports of reduced NTD rates
• Policy renewed 1995
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28. Trends in Wheat-Flour Fortification with Folic
Acid and Iron --- Worldwide, 2004 to 2007
Return to top.
MMWR, 2008;5:8-10 28

29. NTDs, Spina Bifida and Anencephaly
• Serious birth defects
• 1 of 1,000 pregnancies
• 300,000 yearly worldwide
• Increased consumption of folic acid
can prevent 50%-70%
• Diet
• Supplements
• Fortification
• All of the above
From NEJM 1999
Mulinare J. CDC.
National Center on Birth Defects and
Developmental Disabilities, 2003
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30. NTDs In Newfoundland Pre and Post
FA Fortification
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31. NEJM 2007
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33. Fortification Status - June 2010
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35. UK Food Standards Agency
FSA recommends mandatory fortification of bread or
flour with folic acid in order to reduce the risk of
neural tube defects in foetuses.
Currently being considered by UK health ministers,
following advice from the four Chief Medical
Officers in the UK.
If approved, the relevant UK health departments will
be responsible for producing implementation.
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36. .
Yetley E A Am J Clin Nutr 2008;88:558S. American Society for Nutrition
Prevalence of low serum 25-
hydroxyvitamin D concentrations from
the NHANES 2000–2004
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38. Conclusion
• Nutritional security - major public health issue
• Affects MCH, infectious, non infectious disease
• High priority – birth defects, IDA, IDD, CHD
• Fortification has low sex appeal vs. clinical
• Mandatory vs. voluntary – false dilemma
• Requires concern, knowledge, advocacy and
leadership
• Public health role advocacy !!!
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39. Reference/Sources
• World Health Organization
• UNICEF
• Centers for Disease Control, Atlanta NHANES
• American Academy of Pediatrics
• Food and Drug Administration
• GAIN
• Health Canada
• UK Food Standards Agency
• New Public Health chapter 8
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