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Bronder K.L.,Tulane University | Zimmerman S.L.,Food Fortification Initiative | van den Wijngaart A.,Food Fortification Initiative | Codling K.,Food Fortification Initiative | And 3 more authors.
Asia Pacific Journal of Clinical Nutrition | Year: 2017

Background and Objectives: Consumption of foods made with wheat flour, particularly instant noodles, is increasing in Asia. Given this trend, fortifying wheat flour with vitamins and minerals may improve micronutrient intake in the region. The objective of this review was to understand what is known about fortifying wheat flour used to make instant noodles. Methods and Study Design: A literature review of seven databases was performed using the search terms "noodle" and ("Asian" or "instant"). Grey literature was requested through a food fortification listserv. Articles were title screened first for relevance and duplicity, with exclusion criteria applied during the second round of abstract-level screening. This review considered studies examining simulation, retention, sensory, bioavailability, efficacy, and effectiveness of instant noodles made with fortified wheat flour. Results: Fourteen relevant documents were reviewed for simulation (n=1), retention (n=11), and sensory studies (n=3). The documents revealed that instant noodles produced from fortified wheat flour have potential to improve nutrient intakes, have high retention of most nutrients, and provoke no or minimal changes in sensory characteristics. Conclusions: The available literature indicates that using fortified wheat flour for instant noodle production results in retention of the added nutrients, except thiamin, with no significant sensory change to the final product. Given the rising consumption of instant noodles, production of this item with fortified wheat flour has potential to improve nutrient intakes in Asia. This review provides a resource for the design of a wheat flour fortification program in countries where a large proportion of wheat flour is consumed as instant noodles.


Pachon H.,Food Fortification Initiative | Pachon H.,Emory University | Spohrer R.,Global Alliance for Improved Nutrition | Mei Z.,Centers for Disease Control and Prevention | Serdula M.K.,Centers for Disease Control and Prevention
Nutrition Reviews | Year: 2015

Context. More than 80 countries fortify flour, yet the public health impact of this intervention on iron and anemia outcomes has not been reviewed. Objective. The objective of this systematic review was to review published and gray literature pertaining to the impact of flour fortification on iron and anemia. Data Sources. A systematic review was conducted by searching 17 databases and appealing for unpublished reports, yielding 1881 documents. Study Selection. Only studies of government-supported, widely implemented fortification programs in which anemia or iron status was measured prior to and ≥12 months after initiation of fortification were included. Data Extraction. Details about the design, coverage, compliance with national standards, and evaluation (e.g., anemia prevalence before and after fortification) of flour fortification programs were extracted from the reports. Data Synthesis. Thirteen studies describing 26 subgroups (n = 14 for children ≤15 y, n = 12 for women of reproductive age) were included. During the period from pre- to postfortification (and as difference-in-difference for those studies that included a control group), there were statistically significant decreases in the prevalence of anemia in 4 of 13 subgroups of children and in 4 of 12 subgroups of women of reproductive age as well as significant decreases in the prevalence of low ferritin in 1 of 6 subgroups of children and in 3 of 3 subgroups of women of reproductive age. Conclusions. Evidence of the effectiveness of flour fortification for reducing the prevalence of anemia is limited; however, evidence of effectiveness for reducing the prevalence of low ferritin in women is more consistent.


Parra D.C.,Washington University in St. Louis | Iannotti L.,Washington University in St. Louis | Gomez L.F.,Pontifical Xavierian University | Pachon H.,Food Fortification Initiative | And 5 more authors.
Archives of Public Health | Year: 2015

Background: Overweight and underweight increase the risk of metabolic impairments and chronic disease. Interventions at the household level require the diagnosis of nutritional status among family members. The aim of this study was to describe the prevalence and patterns of various anthropometric typologies over a decade in Colombia using a novel approach that considers all children in the household as well as the mother. This approach also allows identifying a dual burden of malnutrition within a household, where one child may be overweight and another one undernourished. Methods: This study used data from the Demographic and Health Survey and the Colombian National Nutrition Survey [2000 n = 2,876, 2005 n = 8,598, and 2010 n = 11,349].Four mutually exclusive household (HH) anthropometric typologies -normal, undernourished, overweight/obese,anddual burden- were created. Anthropometric information of height-for-age Z-scores (HAZ) and body-mass-index-for-age Z-scores (BMIz) in children under the age of 5 y, and on body mass index (BMI) in mothers, 18-49 y was used. Results: Prevalence of overweight/obese HHs increased between 2000 (38.2%) and 2010 (43.1%) (p < 0.05), while undernourished and dual burden HHs significantly decreased between 2005 (13.7% and 10.6%, respectively) and 2010 (3.5% and 5.1%, respectively) (p < 0.05). A greater increase of overweight/obesity was observed for the lowest quintile of wealth index (WI), with an increase of almost 10% between 2000 and 2010, compared to 2% and 4% for the fourth and highest WI, respectively. Although in 2010 there is still a higher prevalence of overweight/obesity HHs in urban areas (43.7%), the prevalence of overweight/obesity HHs in rural areas increased sharply between 2000 (34.3%) and 2010 (41.6%) (p < 0.05).Conclusion: The observed prevalence of dual burden households was not different from the expected prevalence. Results from this study indicate that although overweight/obesity continues to be more prevalent among high-income Colombian households, it is growing at a faster pace among the most economically disadvantaged. © 2015 Parra et al.


Barkley J.S.,Food Fortification Initiative | Barkley J.S.,Emory University | Kendrick K.L.,Emory University | Codling K.,Food Fortification Initiative | And 3 more authors.
Asia Pacific Journal of Clinical Nutrition | Year: 2015

Objective: To summarize anaemia prevalence data for children, women, and men using data from the second, third and fourth waves of the Indonesia Family Life Surveys (IFLS), which were conducted in 1997/8, 2000, and 2007/8, respectively. Methods: Anaemia prevalence was determined for children 0 to 5 years, 5 to 12 years, 12 to 15 years, non-pregnant women at least 15 years, pregnant women at least 15 years, and men at least 15 years, based on haemoglobin adjusted for altitude and smoking status. Results: Compared with 1997/8 estimates, anaemia prevalence estimates were lower in 2007/8 for all groups, with the greatest relative decline occurring in children 5 to 12 years (25.4%). Trend analysis found anaemia significantly declined over the survey years for all groups (χ2 p=0.005 for pregnant women, χ2 p<0.001 for all other groups). Conclusions: IFLS anaemia estimates for different population groups decreased between 1997/8 and 2007/8 and were consistent with estimates from Southeast Asia, and with other studies conducted in Indonesia. While the prevalence of anaemia consistently decreased in all groups, anaemia remains a moderate public health problem for children 0 to 5 years, children 5 to 12 years, and non-pregnant and pregnant women.


Liu P.,Food Fortification Initiative | Bhatia R.,Food Fortification Initiative | Pachon H.,Food Fortification Initiative | Emory,Food Fortification Initiative
Indian Journal of Community Health | Year: 2014

Background: India has a high prevalence of micronutrient deficiency-related health risks, which can be improved by food fortification. Objectives: To identify and analyze single or multiple micronutrient (MMN) food-fortification studies for their efficacy and effectiveness in India. Methods: Papers from searching 10 databases were independently screened by two researchers. Data were abstracted to summarize food fortification results on biological markers, anthropometry, clinical, morbidity, cognition, dietary intake, and physical performance. Results: Forty-seven papers, of which 25 were randomized controlled trials, were included for analysis. Children ≤12 y were the main population (n=38). Food vehicles were cereals (n=6), oils and salts (n=18), and other (e.g., school meals (n=23)). Improvements in ≥1 biological markers were reported in all 35 papers (22 MMN, 9 Iron, 4 Iodine) with interpretable results. More specifically, iron or hemoglobin improvements were noted in all papers fortifying with MMN or solely iron. Iodine nutriture was improved in all salt iodization papers. Eight of 14, 6 of 7, 2 of 6, 4 of 6, 1 of 4, and 1 of 1 papers with interpretable results showed ≥1 positive result of fortification in anthropometry, clinical signs, morbidity, cognition, dietary intake, and physical performance, respectively. Conclusion: Research in India suggests food fortification improves biological markers, particularly iron and hemoglobin when fortifying with MMN or iron. MMN fortification saw more health impacts than using single fortificants. Iodine status was improved through salt iodization. Existing government nutrition programs, especially those that target children, are good avenues for food fortification implementation. © 2014, Indian Association of Preventive and Social Medicine. All rights reserved.


Arth A.,Emory University | Kancherla V.,Emory University | Pachon H.,Food Fortification Initiative | Pachon H.,Emory University | And 3 more authors.
Birth Defects Research Part A - Clinical and Molecular Teratology | Year: 2016

Background: Spina bifida and anencephaly are two major neural tube defects. They contribute substantially to perinatal, neonatal, infant, and under-five mortality and life-long disability. To monitor the progress toward the total prevention of folic acid-preventable spina bifida and anencephaly (FAP SBA), we examined their global status in 2015. Methods: Based on existing data, we modeled the proportion of FAP SBA that are prevented in the year 2015 through mandatory folic acid fortification globally. We included only those countries with mandatory fortification that added at least 1.0 ppm folic acid as a fortificant to wheat and maize flour, and had complete information on coverage. Our model assumed mandatory folic acid fortification at 200 μg/day is fully protective against FAP SBA, and reduces the rate of spina bifida and anencephaly to a minimum of 0.5 per 1000 births. RESULTS: Our estimates show that, in 2015, 13.2% (35,500 of approximately 268,700 global cases) of FAP SBA were prevented in 58 countries through mandatory folic acid fortification of wheat and maize flour. Most countries in Europe, Africa, and Asia were not implementing mandatory fortification with folic acid. Conclusion: Knowledge that folic acid prevents spina bifida and anencephaly has existed for 25 years, yet only a small fraction of FAP SBA is being prevented worldwide. Several countries still have 5- to 20-fold epidemics of FAP SBA. Implementation of mandatory fortification with folic acid offers governments a proven and rapid way to prevent FAP SBA-associated disability and mortality, and to help achieve health-related Sustainable Development Goals. Birth Defects Research (Part A) 106:520–529, 2016. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.


Tsang B.L.,Food Fortification Initiative | Moreno R.,PATH | Dabestani N.,PATH | Pachon H.,Food Fortification Initiative | And 2 more authors.
Food and Nutrition Bulletin | Year: 2016

Background: Fortification of cereal grains with at least iron or folic acid is legislated in 85 countries worldwide. Relative to wheat and maize flour, rice fortification is relatively new and provides an opportunity to deliver essential micronutrients to populations that consume rice as a dietary staple. Objective: To describe miller and public sector experiences and perspectives on rice fortification with micronutrients in Colombia and offer recommendations for policy makers. Methods: Interviews with Colombian rice millers, research and development personnel, and public sector leaders; desk review of key documents. Results: In Colombia, rice fortified with micronutrients is market driven and a few very large rice millers, currently representing about 35% of the market, have voluntarily fortified rice since 2002. The technology used (spraying) is unique to Colombia and to date there is no independent verification of nutrient retention after washing and cooking rice fortified through this technology. Millers are unwilling to switch to more proven methods, such as extrusion or coating, which will incur higher capital investment and recurring costs. Despite interest from multiple stakeholders between 2002 and 2011, mandatory rice fortification is not part of the Colombian government policy as of July 2015. Conclusion: Rice fortified with micronutrients through spraying technology has achieved moderate coverage in Colombia, but the technology is unproven, its effectiveness unknown, and public health impact likely limited. For rice fortification to be an effective nutrition intervention to improve micronutrient status, policy makers should explore standards to guide industry and improvements to regulatory capacity. © Nevin Scrimshaw International Nutrition Foundation.


Barkley J.S.,Food Fortification Initiative | Barkley J.S.,Emory University | Wheeler K.S.,Food Fortification Initiative | Wheeler K.S.,Emory University | And 2 more authors.
British Journal of Nutrition | Year: 2015

The effectiveness of flour fortification in reducing anaemia prevalence is equivocal. The goal was to utilise the existing national-level data to assess whether anaemia in non-pregnant women was reduced after countries began fortifying wheat flour, alone or in combination with maize flour, with at least Fe, folic acid, vitamin A or vitamin B12. Nationally representative anaemia data were identified through Demographic and Health Survey reports, the WHO Vitamin and Mineral Nutrition Information System database and other national-level nutrition surveys. Countries with at least two anaemia surveys were considered for inclusion. Within countries, surveys were excluded if altitude was not consistently adjusted for, or if the blood-draw site (e.g. capillary or venous) or Hb quantification method (e.g. HemoCue or Cyanmethaemoglobin) differed. Anaemia prevalence was modelled for countries that had pre- and post-fortification data (n 12) and for countries that never fortified flour (n 20) using logistic regression models that controlled for time effects, human development index (HDI) and endemic malaria. After adjusting for HDI and malaria, each year of fortification was associated with a 2·4 % reduction in the odds of anaemia prevalence (PR 0·976, 95 % CI 0·975, 0·978). Among countries that never fortified, no reduction in the odds of anaemia prevalence over time was observed (PR 0·999, 95 % CI 0·997, 1·002). Among both fortification and non-fortification countries, HDI and malaria were significantly associated with anaemia (P< 0·001). Although this type of evidence precludes a definitive conclusion, results suggest that after controlling for time effects, HDI and endemic malaria, anaemia prevalence has decreased significantly in countries that fortify flour with micronutrients, while remaining unchanged in countries that do not. © The Authors 2015.


PubMed | Southeast Asian Ministers of Education Organization Regional Center for Food and Nutrition, Food Fortification Initiative and Emory University
Type: Journal Article | Journal: Asia Pacific journal of clinical nutrition | Year: 2015

To summarize anaemia prevalence data for children, women, and men using data from the second, third and fourth waves of the Indonesia Family Life Surveys (IFLS), which were conducted in 1997/8, 2000, and 2007/8, respectively.Anaemia prevalence was determined for children 0 to 5 years, 5 to 12 years, 12 to 15 years, non-pregnant women at least 15 years, pregnant women at least 15 years, and men at least 15 years, based on haemoglobin adjusted for altitude and smoking status.Compared with 1997/8 estimates, anaemia prevalence estimates were lower in 2007/8 for all groups, with the greatest relative decline occurring in children 5 to 12 years (25.4%). Trend analysis found anaemia significantly declined over the survey years for all groups ( p=0.005 for pregnant women, p<0.001 for all other groups).IFLS anaemia estimates for different population groups decreased between 1997/8 and 2007/8 and were consistent with estimates from Southeast Asia, and with other studies conducted in Indonesia. While the prevalence of anaemia consistently decreased in all groups, anaemia remains a moderate public health problem for children 0 to 5 years, children 5 to 12 years, and non-pregnant and pregnant women.


PubMed | Food Fortification Initiative and Emory University
Type: Journal Article | Journal: Birth defects research. Part A, Clinical and molecular teratology | Year: 2016

Spina bifida and anencephaly are two major neural tube defects. They contribute substantially to perinatal, neonatal, infant, and under-five mortality and life-long disability. To monitor the progress toward the total prevention of folic acid-preventable spina bifida and anencephaly (FAP SBA), we examined their global status in 2015.Based on existing data, we modeled the proportion of FAP SBA that are prevented in the year 2015 through mandatory folic acid fortification globally. We included only those countries with mandatory fortification that added at least 1.0 ppm folic acid as a fortificant to wheat and maize flour, and had complete information on coverage. Our model assumed mandatory folic acid fortification at 200 g/day is fully protective against FAP SBA, and reduces the rate of spina bifida and anencephaly to a minimum of 0.5 per 1000 births.Our estimates show that, in 2015, 13.2% (35,500 of approximately 268,700 global cases) of FAP SBA were prevented in 58 countries through mandatory folic acid fortification of wheat and maize flour. Most countries in Europe, Africa, and Asia were not implementing mandatory fortification with folic acid.Knowledge that folic acid prevents spina bifida and anencephaly has existed for 25 years, yet only a small fraction of FAP SBA is being prevented worldwide. Several countries still have 5- to 20-fold epidemics of FAP SBA. Implementation of mandatory fortification with folic acid offers governments a proven and rapid way to prevent FAP SBA-associated disability and mortality, and to help achieve health-related Sustainable Development Goals. Birth Defects Research (Part A) 106:520-529, 2016. 2016 Wiley Periodicals, Inc.

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