Food Fortification in Public Health Policy TH Tulchinsky MD MPH Braun SPH 11 Nov 2003

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 strategyFood based strategy –Socio economic factors –Food supply/costs –Education Supplementation for target groupsSupplementation for target groups –Women and children –Elderly Fortification of basic foodsFortification of basic foods Surveillance and monitoringSurveillance and monitoring

18-19 th 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

Iron Suppl. Iron Fort.Iodine Suppl. Iodine Fort. Vit A Suppl. Vit A Fort. US Dollars Low Cost Solutions to Eliminate Micronutrient Malnutrition Source: World Bank, 1994 Annual Per Capita Cost of Interventions

Productivity Gained per US$ Expended $13.8 $24.7 $28.0 $47.5 $84.1 $146.0 $0 $25 $50 $75 $100 $125 $150 Fe Suppl. (Wom.) Fe Suppl. (Preg. Wom.) Iodine Fort. Vit.A Fort. Fe Fort.Vit.A Suppl. Relative Cost Effectiveness of Micronutrient Interventions Source: UNICEF/UNU/WHO/MI, 1999

Vital Amines 1900, nutrition - calories, fats, carbohydrates proteins 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

More on Vitamins 1931, Fluoride shown to prevent tooth decay 1932, Vitamin C and riboflavin isolated 1933, Williams - kwashiorkor as vitamin deficiency 1941, Prenatal diet and health of newborn 1945, Fluoridation of water Grand Rapids 1948, Vitamin B12 isolated 1949, Framingham study begins

Key Landmarks Morton’s 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 , 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 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 , 3 million cases and 100,000 deaths attributed to pellagra

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Rickets 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

Global Burden of Micronutrient Deficiencies Iron deficiency - all ages Chronic undernutrition – all ages Iodine deficiency – pregnancy Vitamin A deficiency – young children PEM – young children Folic acid deficiency – all ages  2 billion*  1 billion*  200 million**  200 million*  167 million*  Unknown Source WHO

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 RegionAnemic or Iron Deficient Prevalence of Anemia in Pregnancy Africa America Europe E. Mediterranean S.E. Asia Western Pacific Source WHO

Benefits of Preventing Iron Deficiency  Benefits to children Improved behavioral and cognitive development Improved child survival (where severe anemia is common)  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 mortality 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, Months Old *Hgb <10.3 g/dL Yip et al., JAMA, 1987

 Preschool children  School age children and adolescents  Non-pregnant women  Pregnant women  Adult men

* Based on serum ferritin model NHANES III (Ogden et al., 1998) Prevalence of iron deficiency* by income and race/ethnicity, U.S., 1-4 year olds,

US Federal Policy USDA extension programs , 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 reform

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, Alzheimer’s 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 <1/3 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

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Folic Acid and Heart Disease High homocysteine levels associated with excess CHD, birth defects, Alzheimer’s 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

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

Problems with Fortification Policy Antagonism to trends in North America 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 Clinical vs. population approaches Manufacturer’s and regulatory agency attitudes

Progress 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

Conclusion Nutrition a 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

Referents World Health Organization UNICEF CDC American Academy of Pediatrics American College Obstetrics and Gynecology Food and Drug Administration Health Canada