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Impact of flour fortification with calcium on calcium intake: a simulation study in seven countries.

ABSTRACT: Calcium intake is low in many countries, especially in low-income countries. Our objective was to perform a simulation exercise on the impact, effectiveness, and safety of a flour fortification strategy using the Intake Modelling, Assessment, and Planning Program. Modeling of calcium fortification scenarios was performed with available dietary intake databases from Argentina, Bangladesh, Italy, the Lao People's Democratic Republic (Lao PDR), Uganda, Zambia, and the United States. This theoretical exercise showed that simulating a fortification with 156 mg of calcium per 100 g of flour would decrease the prevalence of low calcium intake, and less than 2% of the individuals would exceed the recommended calcium upper limit (UL) in Argentina, Italy, Uganda, and Zambia. Bangladesh and the Lao PDR showed little impact, as flour intake is uncommon. By contrast, in the United States, this strategy would lead to some population groups exceeding the UL. This exercise should be replicated and adapted to each country, taking into account the updated prevalence of calcium inadequacy, flour consumption, and technical compatibility between calcium and the flour-type candidate for fortification. A fortification plan should consider the impact on all age groups to avoid the risk of exceeding the upper levels of calcium intake.

SUBMITTER: Cormick G

PROVIDER: S-EPMC9290501 | biostudies-literature | 2021 Jun

REPOSITORIES: biostudies-literature

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Impact of flour fortification with calcium on calcium intake: a simulation study in seven countries.

Cormick Gabriela G Betran Ana Pilar AP Romero Iris B IB García-Casal María Nieves MN Perez Surya M SM Gibbons Luz L Belizán José M JM

Annals of the New York Academy of Sciences 20210111 1

Calcium intake is low in many countries, especially in low-income countries. Our objective was to perform a simulation exercise on the impact, effectiveness, and safety of a flour fortification strategy using the Intake Modelling, Assessment, and Planning Program. Modeling of calcium fortification scenarios was performed with available dietary intake databases from Argentina, Bangladesh, Italy, the Lao People's Democratic Republic (Lao PDR), Uganda, Zambia, and the United States. This theoretica ...[more]

PMID: 33432622

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Project description:BackgroundSince 2011 Cameroon has mandated the fortification of refined vegetable oil with vitamin A and wheat flour with iron, zinc, folic acid, and vitamin B-12. In 2012, measured fortification levels for flour, and particularly oil, were below target.ObjectivesWe assessed Cameroon's food fortification program using a program impact pathway (PIP) to identify barriers to optimal performance.MethodsWe developed a PIP through literature review and key informant interviews. We conducted interviews at domestic factories for refined vegetable oil (n = 9) and wheat flour (n = 10). In 12 sentinel sites distributed nationally, we assessed availability and storage conditions of fortified foods in markets and frequency of consumption of fortified foods among women and children (n = 613 households). Food samples were collected from factories, markets, and households for measurement of micronutrient content.ResultsTwo-thirds of factories presented quality certificates for recent premix purchases. All factories had in-house capacity for micronutrient analysis, but most used qualitative methods. Industries cited premix import taxes and access to external laboratories as constraints. Mean vitamin A levels were 141% (95% CI: 116%, 167%), 75% (95% CI: 62%, 89%), and 75% (95% CI: 60%, 90%) of target in individual samples from factories, markets, and households, respectively. Most industry flour samples appeared to be fortified, but micronutrient levels were low. Among composite flour samples from markets and households, the mean iron and zinc content was 25 mg/kg and 43 mg/kg, respectively, ∼45% of target levels; folic acid (36%) and vitamin B-12 (29%) levels were also low. In the previous week, the majority of respondents had consumed "fortifiable" oil (63% women and 52% children) and wheat flour (82% women and 86% children).ConclusionsIn Cameroon, oil fortification program performance appears to have improved since 2012, but fortification levels remain below target, particularly for wheat flour. Consistent regulatory monitoring and program support, possibly through premix procurement and micronutrient analysis, are needed.

Project description:IntroductionIn 1996, the US Food and Drug Administration (FDA) mandated folic acid fortification for all enriched cereal grains. This resulted in a reduction of neural tube defect (NTD)-affected pregnancies. However, Hispanic women continued to be twice as likely to give birth to a child affected by NTD compared to non-Hispanic White women. Some hypotheses explaining this difference focus on cultural variation in dietary intake of cereal grains. In 2016, the FDA approved voluntary folic acid fortification for corn masa flour products to focus on the Hispanic diet staple. This study investigates rates of NTDs in predominantly Hispanic-populated zip codes before and after the voluntary fortification of corn masa flour with folic acid.MethodsNormal pregnancies and those complicated by NTDs between 1/1/2016 and 9/30/2020 were identified using ICD-9 and ICD-10 codes in an all-payor claims database. The post-fortification period began 12 months after the fortification recommendation. The US Census data was used to stratify pregnancies in predominantly Hispanic zip codes (≥ 75% of households) vs. non-Hispanic zip codes. The causal impact of the FDA's recommendation was assessed by means of a Bayesian structural time series model.ResultsA total of 2,584,366 pregnancies were identified among females aged 15-50 years. Of these, 365,983 took place in predominantly Hispanic zip codes. Mean quarterly NTDs per 100,000 pregnancies did not significantly differ between predominantly Hispanic zip codes and predominantly non-Hispanic zip codes pre-FDA recommendation (184.5 vs. 175.6; p = 0.427), nor post-recommendation (188.2 vs. 185.9; p = 0.713). Rates of NTDs predicted to occur if no FDA recommendation had been made were compared to the actual rate post-recommendation: no significant difference was observed in predominantly Hispanic zip codes (p = 0.245) or overall (p = 0.116).ConclusionsRates of neural tube defects were not significantly reduced in predominantly Hispanic zip codes following the 2016 FDA approval of voluntary folic acid fortification of corn masa flour. Further research and implementation of comprehensive approaches to advocacy, policy, and public health are necessary to decrease preventable congenital disease rates. Mandatory rather than voluntary fortification of corn masa flour products may achieve more substantial prevention of neural tube defects in at-risk US populations.

Project description:This paper comprehensively investigates various aspects of dietary behaviors relating to the usage of wheat flour and sociocultural preferences embedded within rural communities and aims to bridge health gaps resulting from zinc deficiency by introducing zinc bio-fortified and fortified flour in Pakistan. A household and a market study was conducted in Ghotki and Tando Muhammad Khan districts in Sindh, Pakistan. Various stakeholders involved in the wheat-flour industry including farmers, seed suppliers, owners of atta-chakkis and flour mills, grocers and flour merchants, bakers and hoteliers, consumers, and agronomists were interviewed to gauge their knowledge of bio-fortified and fortified wheat-flour. Wheat-flour is a staple food item in Pakistan, however, agricultural output in Pakistan varies across all provinces. Factors that hinder agricultural productivity include a shortfall of essential resources such as irrigation water, superior quality seeds and fertilizers, and machinery. Farmers use primitive methods of farming as they do not have access to modern technologies, information, or training. Wheat flour market vendors and consumers lack awareness of bio-fortified and fortified wheat flour products and believe the only way to create a customer-base is by ensuring that fortified wheat products are available to all and competitively priced compared to traditional options. Additionally, participants misconstrue the process of fermentation and perceive it as unhealthy. The lack of financial resources and awareness restricts adequate promotion of nutrient-rich food products amongst stakeholders involved in the wheat flour industry. Mass awareness campaigns, education and government incentives could bridge the gaps present and encourage wider adoption of bio-fortified and fortified wheat flour. Policy makers and communities can draw on the recommendations made in this paper to introduce and promote zinc bio-fortified and zinc-fortified flour in settings where zinc deficiency is prevalent.

Dataset Information

Impact of flour fortification with calcium on calcium intake: a simulation study in seven countries.

Publications

Impact of flour fortification with calcium on calcium intake: a simulation study in seven countries.

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