Comprehensive Strategies for Food Fortification in Public Health Policy

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

2. 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

3. 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

4. 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

5. Low Cost Solutions to Eliminate Micronutrient Malnutrition 4 3 Annual Per Capita Cost of Interventions 2 US Dollars 1 0 Iron Iron Fort . Iodine Iodine Vit A Vit A Suppl . Suppl . Fort . Suppl . Fort . Source: World Bank, 1994

6. Relative Cost Effectiveness of Micronutrient Interventions Productivity Gained per US$ Expended $ 146 . 0 $ 150 $ 125 $ 100 $ 84 . 1 $ 75 $ 47 . 5 $ 50 $ 28 . 0 $ 24 . 7 $ 13 . 8 $ 25 $ 0 Fe Suppl . Fe Suppl . Iodine Vit . A Fe Fort . Vit . A ( Wom .) ( Preg . Fort . Fort . Suppl . Wom .) Source: UNICEF/UNU/WHO/MI, 1999

7. 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

8. 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

9. 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

10. 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

11. Iodine Fortification of Salt in the U.S.: Trend in Goiter Prevalence in Michigan WHO Monograph Series N. 44

12. 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

13. Figure 2

14. 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

15. 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

16. 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

17. Global Burden of Iron Deficiency • Source WHO

18. Benefits of PreventingIron 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)

19. 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

20. Trends in Prevalence of Anemia* in Low-income U.S. Children, 12-17 Months Old *Hgb <10.3 g/dL Yip et al., JAMA, 1987

21. Preschool children • School age children and adolescents • Non-pregnant women • Pregnant women • Adult men

22. Prevalence of iron deficiency* by income and race/ethnicity, U.S., 1-4 year olds, 1988-94 *Based on serum ferritin model NHANES III (Ogden et al., 1998)

23. 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

24. 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

25. 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

26. 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

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, from 1998 • Canada and UK also mandate folic acid fortification of flour • New paradigm in public health

28. Table Return to top.Figure

29. Figure

31. 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

32. 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

33. 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

34. 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

35. 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

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