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 strategy
– Socio economic factors
– Food supply/costs
– Education
• Supplementation for target groups
– Women and children
– Elderly
• Fortification of basic foods
• Surveillance and monitoring
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
Low Cost Solutions to Eliminate
Micronutrient Malnutrition
4
US Dollars
3
Annual Per Capita Cost of Interventions
2
1
0
Iron
Suppl .
Iron Fort.
Iodine
Suppl.
Iodine
Fort.
Vit A
Suppl.
Vit A
Fort.
Source: World Bank, 1994
Relative Cost Effectiveness of
Micronutrient Interventions
Productivity Gained per US$ Expended
$ 146.0
$ 150
$ 125
$ 100
$ 75
$ 50
$ 25
$0
$ 84.1
$ 47.5
$ 13.8
Fe Suppl.
( Wom.)
$ 24.7
Fe Suppl.
( Preg.
Wom.)
$ 28.0
Iodine
Fort.
Vit. A
Fort.
Fe Fort.
Vit. A
Suppl.
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
• 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
• Many countries achieved iodization
Percent
Iodine Fortification of Salt in the U.S.:
Trend in Goiter Prevalence in
Michigan
Year
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
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
 2 billion*
Chronic undernutrition – all ages  1 billion*
Iodine deficiency – pregnancy
 200 million**
Vitamin A deficiency – young
 200 million*
children
• PEM – young children
 167 million*
• Folic acid deficiency – all ages  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 Region Anemic or Iron
Deficient
Africa
America
Europe
E. Mediterranean
S.E. Asia
Western Pacific
•Source WHO
206
94
27
149
616
1058
Prevalence of
Anemia in
Pregnancy
52
60
18
50
74
40
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 Lowincome U.S. Children, 12-17 Months Old
Program Enrollment
Percent
Follow-up
*Hgb <10.3 g/dL
Yip et al., JAMA, 1987
Birth Year
 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
<=
>
white
*Based
% poverty
% poverty
black
on serum ferritin model
NHANES III (Ogden et al., 1998)
MexicanAmerican
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 reform
Nutrition Interactions
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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
Return to top.
Figure
Figure
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
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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
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World Health Organization
UNICEF
CDC
American Academy of Pediatrics
American College Obstetrics and
Gynecology
• Food and Drug Administration
• Health Canada