Food Fortification in Public Health Policy

1
Food Fortification in Public Health Policy

• TH Tulchinsky MD MPH
• Braun SPH
• 11 Nov 2003

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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

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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
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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
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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

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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

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Key Landmarks

• Mortons 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

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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, Mortons Iodized Salt (N America)
• 1979, Iodization mandatory in Canada
• 1980s, WHO - universal iodization of salt
• Many countries achieved iodization

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

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Figure 2                                       
                                            
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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

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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

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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

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Global Burden of Iron Deficiency
WHO Region Anemic or Iron Deficient Prevalence of Anemia in Pregnancy
Africa America Europe E. Mediterranean S.E. Asia Western Pacific 206 94 27 149 616 1058 52 60 18 50 74 40

• Source WHO

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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)

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• 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

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Trends in Prevalence of Anemia in Low-income
U.S. Children, 12-17 Months Old
Hgb lt10.3 g/dL Yip et al., JAMA, 1987
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• Preschool children
• School age children
• and adolescents
• Non-pregnant women
• Pregnant women
• Adult men

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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)
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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

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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

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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

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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, Alzheimers Disease
• Nutrition and cancer
• Nutrition and cardiovascular disease
• Nutrition and diabetes
• Nutrition in disease management

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Folic Acid and NTDs

• Pre pregnancy folic acid supplements prevent
  neural tube defects, 1980s
• Supplements to women in age of fertility achieves
  lt1/3 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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Table Return to top. Figure
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Figure
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(No Transcript)
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Folic Acid and Heart Disease

• High homocysteine levels associated with excess
  CHD, birth defects, Alzheimers 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

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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

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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
• Manufacturers and regulatory agency attitudes

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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

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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

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Referents

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