1. Nutrition Security through Food Fortification
Manjari Chandra
Senior Consultant : Nutrition
Max Healthcare
MSc, DHA, DE
AdvisoR: NAEP, Heal
Panelist : CNN , NDTV, Zee, India today

2. Micronutrient deficiency malnutrition
Worldwide, the most common forms of MNM are iron, vitamin A and iodine deficiency.
Together, these affect at least one third of the world’s population, the majority of whom are in developing countries.
Of the three, iron deficiency is the most prevalent.
It is estimated that just over 2 billion people are anaemic.
Just under 2 billion have inadequate iodine nutrition.
254 million preschool-aged children are vitamin A deficient.

4. MNM : Effects

5. Strategies to control MNM
Food fortification: Tends to have a less immediate but a much wider and more sustained impact. Food fortification has been identified by the World Health Organization, the Copenhagen Consensus and the Food and Agriculture Organization as one of the top four strategies for decreasing micronutrient malnutrition at the global level. 
Increasing the diversity of foods consumed: Entails increasing both the quantity and the range of micronutrient-rich foods consumed. In practice, this requires the implementation of programs that improve the availability and consumption of, and access to, different types of micronutrient-rich foods (such as animal products, fruits and vegetables) in adequate quantities, especially among those who at risk for, or vulnerable to, MNM.

6. Strategies to control MNM
Supplementation: Provision of relatively large doses of micronutrients, usually in the form of pills, capsules or syrups. It has the advantage of being capable of supplying an optimal amount of a specific nutrient or nutrients, in a highly absorbable form, and is often the fastest way to control deficiency in individuals or population groups that have been identi- fied as being deficient.
Public health measures: Public health measures of a more general nature are often required to help prevent and correct MNM, because MNM is often associated with poor overall nutritional status and with a high prevalence of infection. Such measures include infection control (e.g. immunization, malaria and parasite control), and improvement of water and sanitation.

7. Food fortification : Efficacy trials
Efficacy trials evaluate the impact of a test intervention under ideal circumstances.
In the majority of efficacy trials conducted to date, fortified foods have been shown to improve micronutrient status.

8. Iron fortification: Efficacy trials
In Viet Nam, 6-month efficacy trials have established that fortification of fish sauce with iron can significantly improve iron status and reduce anemia and iron deficiency . Thuy PV et al. Regular consumption of NaFeEDTA-fortified fish sauce improves iron status and reduces the prevalence of anemia in anemic Vietnamese women. American Journal of Clinical Nutrition, 2003, 78:284–290.
In China, a series of studies have been conducted to assess the efficacy, effectiveness and feasibility of fortifying soy sauce with iron (in the form of NaFeEDTA). Daily consumption of 5mg or 20mg iron in the fortified sauce was reported to be very effective in the treatment of iron-deficiency anaemia in children; positive effects were seen within 3 months of the start of the intervention Mannar V, Boy Gallego E. Iron fortification: country level experiences and lessons learned. Journal of Nutrition, 2002, 132 (4 Suppl):856S–858S

9. Iron fortification: Efficacy trials
In an iron-deficient Indian population in South Africa, fortification of curry powder with NaFeEDTA produced significant improvements in blood haemoglobin, ferritin levels and iron stores in women, and in ferritin levels in men (30). During the 2-year study, the prevalence of iron-deficiency anaemia in women fell from 22% to just 5%. Ballot DE et al. Fortification of curry powder with NaFe(111)EDTA in an irondeficient population: report of a controlled iron-fortification trial. American Journal of Clinical Nutrition, 1989, 49:162–169.
Iron fortification of infant formulas has been associated with a fall in the prevalence of anaemia in children aged under 5 years in the United States . Fomon S. Infant feeding in the 20th century: formula and beikost. Journal of Nutrition, 2001, 131:409S–420S.

10. Vitamin A fortification: Efficacy trials
Trials conducted in the Philippines have revealed that fortification of monosodium glutamate with vitamin A produces positive effects on child mortality, and improved growth and haemoglobin levels in children . Muhilal et al. Vitamin A-fortified monosodium glutamate and health, growth, and survival of children: a controlled field trial. American Journal of Clinical Nutrition, 1988, 48:1271–1276
Later studies with preschool-aged children, who consumed 27g of vitamin A-fortified margarine per day for a period of 6 months, reported a reduction in the prevalence of low serum retinol concentrations from 26% to 10% . Solon FS et al. Evaluation of the effect of vitamin A-fortified margarine on the vitamin A status of preschool Filipino children. European Journal of Clinical Nutrition, 1996, 50:720–723.

11. Iodine fortification: Efficacy trials
Numerous studies, particularly from the developed world, have clearly established that salt iodization is an effective means of controlling iodine deficiency.
In the United States, large-scale iodization of salt in Michigan reduced the goitre rate from about 40% to below 10% . Marine D, Kimball OP. Prevention of simple goiter in man. Archives of Internal Medicine, 1920, 25:661–672.
In the early 20th century almost all Swiss schoolchildren had goitre and 0.5% of the population had cretinism.When salt iodization was introduced in 1922, the prevalence of goitre and deaf mutism in children dropped dramatically.
Iodine deficiency disorders (IDD) control programme in India is one of the success stories of public health in the country.

12. Folic acid fortification: Efficacy trials
The introduction of the mandatory fortification of wheat flour with folic acid in the United States in 1998 was accompanied by a significant reduction in the prevalence of neural tube defects and in plasma levels of homocysteine. Honein MA et al. Impact of folic acid fortification of the US food supply on the occurrence of neural tube defects. Journal of the American Medical Association, 2001, 285:2981–2986.
Similar improvements in folate status have been seen after the commencement of folic acid fortification of wheat flour in Canada. Ray JG et al. Association of neural tube defects and folic acid food fortification in Canada. Lancet, 2002, 360:2047–2048.

13. Vitamin D fortification: Efficacy trials
The virtual elimination of childhood rickets in the industrialized countries has been largely attributed to the addition of vitamin D to milk, a practice that commenced in the 1930s in Canada and the United States.
In a recent study of African American women, a low intake of vitamin D fortified milk was found to be a significant predictor of a high prevalence of vitamin D deficiency . Nesby-O’Dell S et al. Hypovitaminosis D prevalence and determinants among African American and white women of reproductive age: third National Health and Nutrition Examination Survey, 1988–1994. American Journal of Clinical Nutrition, 2002, 76:187–192.
Vitamin D fortification of milk also reduces the risk of osteoporosis in the elderly, especially in higher latitude regions where levels of incident ultraviolet light are lower during the winter months . Keane EM et al. Vitamin D-fortified liquid milk: benefits for the elderly community-based population. Calcified Tissue International, 1998, 62:300–302.

14. Diseases food fortification can address!!
Spina Bifida 
Each year 1,500 babies are born with Spina Bifida, just in the US alone. Spina Bifida is a fault in the development of the spine and the spinal cord, which leaves a gap in the spine. The effects can range from paralysis to severe brain damage.
Increasingly governments are making flour fortification mandatory, adding folic acid to your weekly diet.

15. Goiter Night Blindness
A goiter is an inflammation in the thyroid gland.
Goiters are usually a result of iodine deficiency, one of the world’s most prevalent, yet easily preventable causes of brain damage.
Adding iodine to salt can fight goiter and other iodine deficiencies, and is the simplest, safest and most inexpensive intervention to ensure an adequate iodine intake. The World Bank reports that global salt iodization would cost just US$0.05 per child per year.
Night Blindness 
Vitamin A deficiency is the leading cause of preventable blindness in children, affecting million children around the world. Large scale fortification programs add Vitamin A to maize, wheat flour, or oil, providing people with Vitamin A, even if they can’t afford to eat a diverse diet.

16. Rickets
Rickets affects bone development, causing the bones to become soft and weak. The most common cause is a lack of vitamin D and calcium
In several countries, such as the US, fortifying milk with Vitamin D is mandatory. Some breakfast cereals are also fortified with calcium and Vitamin D.
Anaemia
Anaemia is a serious iron deficiency, which can result in delayed development in children and affect the mental functioning of teens. Anaemia is also the leading cause of maternal death.
By 2017, the aim was to reach 1.3 billion people, including 400 million women and adolescent girls and 200 million children under 5 through large-scale food fortification programs which support the additional intake of critical micronutrients.

17. Advantages of food fortification to combat MNM
If consumed on a regular and frequent basis, fortified foods will maintain body stores of nutrients more efficiently and more effectively than will intermittent supplements.
Fortified foods are also better at lowering the risk of the multiple deficiencies that can result from seasonal deficits in the food supply or a poor quality diet.
Fortification generally aims to supply micronutrients in amounts that approximate to those provided by a good, well-balanced diet. Consequently, fortified staple foods will contain “natural” or near natural levels of micronutrients, which may not necessarily be the case with supplements.
Fortification of widely distributed and widely consumed foods has the potential to improve the nutritional status of a large proportion of the population, both poor and wealthy.

18. Advantages of food fortification to combat MNM
Fortification requires neither changes in existing food patterns – which are notoriously difficult to achieve, especially in the short-term – nor individual compliance.
In most settings, the delivery system for fortified foods is already in place, generally through the private sector.
It is usually possible to add one or several micronutrients without adding substantially to the total cost of the food product at the point of manufacture.
When properly regulated, fortification carries a minimal risk of chronic toxicity.

19. Thank You!! Manjari Chandra Senior Consultant : Nutrition
Max Healthcare
MSc, DHA, DE
Advisor: NAEP, Heal
Panelist : CNN , NDTV, Zee, India today