Food Fortification as Public Health Policy TH Tulchinsky MD MPH Braun SPH 24 November

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WHO, FAO

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 4

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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 11

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 12

18-19 th 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) 13

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 14

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 15

Low Cost Solutions to Eliminate Micronutrient Malnutrition Source: World Bank, 1994 Annual Per Capita Cost of Interventions World Bank

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 Most member countries achieved iodization 17

Iodine Fortification of Salt in the U.S.: Trend in Goiter Prevalence in Michigan WHO Monograph Series N

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 19

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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) 21

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 22

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 23

Trends in Prevalence of Anemia* in Low-income U.S. Children, Months Old * Hgb <10.3 g/dL Yip et al., JAMA,

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

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

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

Trends in Wheat-Flour Fortification with Folic Acid and Iron --- Worldwide, 2004 to 2007 Figure Return to top. Return to top. MMWR, 2008;5:

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,

NTDs In Newfoundland Pre and Post FA Fortification 30

NEJM

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Fortification Status - June 2010 Fortification Status - June

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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. 35

. Yetley E A Am J Clin Nutr 2008;88:558S. American Society for Nutrition -564S Prevalence of low serum 25- hydroxyvitamin D concentrations from the NHANES 2000–

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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 !!! 38

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 39