Improved micronutrient status and health outcomes in low- and middle-income countries following large-scale fortification: evidence from a systematic review and meta-analysis

Expanding Fortification with Folic Acid: Thinking Outside the Cereal-Grain Box

(1) Background: Fortifying maize and wheat flours with folic acid has effectively reduced neural tube defect-affected births. However, maize and wheat flours may not be widely consumed in all countries; further reduction in neural tube defect-affected births could benefit from the identification of alternative food vehicles. We aimed to use dietary intake or apparent consumption data to determine alternative food vehicles for large-scale fortification with folic acid in low-income and lower-middle-income countries (LILMICs) and identify current research related to examining the technological feasibility of fortifying alternative foods with folic acid. (2) Methods: We identified 81 LILMICs, defined by the World Bank's (WB) 2018 income classifications. To identify dietary intake or apparent consumption, we reviewed WB's Microdata Library and Global Health Data Exchange for national surveys from 1997-2018. We reviewed survey reports for dietary intake or apparent consumption data and analyzed survey datasets for population coverage of foods. We defined alternative food vehicles as those that may cover/be consumed by ≥30% of the population or households; cereal grains (maize and wheat flours and rice) were included as an alternative food vehicle if a country did not have existing mandatory fortification legislation. To identify current research on fortification with folic acid in foods other than cereal grains, we conducted a systematic review of published literature and unpublished theses, and screened for foods or food products. (3) Results: We extracted or analyzed data from 18 national surveys and countries. The alternative foods most represented in the surveys were oil (n = 16), sugar (n = 16), and salt (n = 14). The coverage of oil ranged from 33.2 to 95.7%, sugar from 32.2 to 98.4%, and salt from 49.8 to 99.9%. We found 34 eligible studies describing research on alternative foods. The most studied alternative foods for fortification with folic acid were dairy products (n = 10), salt (n = 6), and various fruit juices (n = 5). (4) Conclusions: Because of their high coverage, oil, sugar, and salt emerge as potential alternative foods for large-scale fortification with folic acid. However, except for salt, there are limited or no studies examining the technological feasibility of fortifying these foods with folic acid.

High Dietary Folic Acid Supplementation Reduced the Composition of Fatty Acids and Amino Acids in Fortified Eggs

AIMS

The study aimed to evaluate the effects of dietary folic acid (FA) on the production performance of laying hens, egg quality, and the nutritional differences between eggs fortified with FA and ordinary eggs.

METHODS

A total of 288 26-week-old Hy-Line Brown laying hens (initial body weights 1.65 ± 0.10 kg) with a similar weight and genetic background were used. A completely randomized design divided the birds into a control group and three treatment groups. Each group consisted of six replicates, with twelve chickens per replicate. Initially, all birds were fed a basal diet for 1 week. Subsequently, they were fed a basal diet supplemented with 0, 5, 10, or 15 mg/kg FA in a premix for a duration of 6 weeks.

RESULTS

Supplementation of FA could significantly (p < 0.05) enhance the FA content in egg yolks, particularly when 10 mg/kg was used, as it had the most effective enrichment effect. Compared to the control group, the Glu content in the 10 and 15 mg/kg FA groups showed a significant (p < 0.05) decrease. Additionally, the contents of Asp, Ile, Tyr, Phe, Cys, and Met in the 15 mg/kg FA group were significantly (p < 0.05) lower compared to the other groups. Adding FA did not have significant effects on the levels of vitamin A and vitamin E in egg yolk, but the vitamin D content in the 5 and 10 mg/kg FA groups showed a significant (p < 0.05) increase. Furthermore, the addition of FA did not have a significant effect on the levels of Cu, Fe, Mn, Se, and Zn in egg yolk. The dietary FA did not have a significant effect on the total saturated fatty acids (SFA) and polyunsaturated fatty acid (PUFA) content in egg yolk. However, the total monounsaturated fatty acid (MUFA) content in the 5 and 10 mg/kg groups significantly (p < 0.05) increased. These changes in nutritional content might be attributed to the increased very low-density lipoprotein (VLDL) protein content. The significant decrease in solute carrier family 1 Member 1 (SLC1A1), solute carrier family 1 Member 2 (SLC1A2), and solute carrier family 1 Member 3 (SLC1A3) gene expression compared to the control group appeared to be the reason for the decrease in amino acid content in egg yolk within the dietary FA group.

CONCLUSION

The findings suggest that the appropriate addition of FA can enhance the levels of MUFA and vitamin D in egg yolks, thereby improving their nutritional value. Excessive intake of FA can decrease the effectiveness of enriching FA in egg yolk and impact the enrichment of certain amino acids. The yolk of eggs produced by adding 10 mg/kg of FA to the feed contains the optimal amount of nutrients. This study informs consumers purchasing FA-fortified eggs.

Folic Acid-Fortified Iodized Salt and Serum Folate Levels in Reproductive-Aged Women of Rural India: A Nonrandomized Controlled Trial

Importance

India has a disproportionately high prevalence of neural tube defects, including spina bifida and anencephaly (SBA), causing a high number of stillbirths, elective pregnancy terminations, and child mortality; India contributes a large proportion of the global burden of SBA. Thirty years after folic acid was shown to be effective in reducing SBA prevalence, only about one-quarter of such births are prevented globally through cereal grain fortification.

Objective

To determine the association of folic acid-fortified iodized salt with serum folate concentrations among nonpregnant and nonlactating women of reproductive age.

Design, Setting, and Participants

This nonrandomized controlled trial using a preintervention and postintervention design was conducted in 4 rural villages in Southern India from July 1 to November 30, 2022. All households in the villages agreed to participate in the study. Preintervention and postintervention serum folate levels were analyzed among study participants at baseline and after 4 months, respectively.

Intervention

Consumption of approximately 300 µg/d of folic acid using double fortified salt (folic acid plus iodine). Median serum folate concentrations were assessed at baseline and 4 months.

Main Outcomes and Measures

Change in median serum folate levels between baseline and study end point as the primary outcome of the study.

Results

A total of 83 nonpregnant nonlactating women aged 20 to 44 years (mean [SD] age, 30.9 [5.1] years) were eligible for the study and provided serum samples for analysis at baseline and the end point of the intervention. The median serum folate concentration increased from 14.6 (IQR, 11.2-20.6) nmol/L at baseline to 54.4 (IQR, 43.5-54.4) nmol/L at end of study, a 3.7-fold increase from baseline to study end point. Two-tailed Wilcoxon signed rank test showed the median difference in preintervention and postintervention serum folate concentrations to be highly significant (P < .001). The participants found the salt acceptable in color and taste.

Conclusions and Relevance

Use of folic acid-fortified iodized salt was associated with increased serum folate concentrations in women of reproductive age. This novel evidence can inform public health policy to accelerate SBA prevention.

Trial Registration

ClinicalTrials.gov Identifier: NCT06174883.

A review of the dietary diversity and micronutrient adequacy among the women of reproductive age in low- and middle-income countries

The dietary quality of women of reproductive age (WRA) is particularly important during preconception, conception, and pregnancy for themselves and their offspring. Poorly diversified diets resulting in inadequate micronutrient consumption may have adverse effects on their health. This narrative review summarizes the findings of studies reporting on dietary diversity and micronutrient intake by WRA in low- and middle-income countries (LMICs). Studies on WRA aged 15-49 years in LMICs, with a sample size of more than 150, report dietary diversity and multiple micronutrient intake based on 24-h dietary recall/food weighed record/food frequency questionnaire, and published between January 2011 and June 2021 were included. The results were compared to the Food and Agriculture Organization (FAO) recommended cut-off for dietary diversity and the Indian Council of Medical Research (ICMR) recommended age- and sex-specific estimated average requirements (EARs) for micronutrient intake. This review includes 35 articles, of which 21 focused on dietary diversity and 14 on micronutrient intake. The results showed that WRA in LMICs had inadequate dietary diversity, with mean food group consumption of only 3.0-4.84, and around 42.3%-90% of women consumed inadequately diversified diets (<5 food groups). Additionally, most studies found that WRA did not consume adequate amounts of essential micronutrients, particularly calcium, iron, zinc, vitamin A, thiamin, riboflavin, folate, and vitamin B12. However, the intake of vitamin C, niacin, and vitamin B6 was above the required levels. In conclusion, this review highlights the common inadequacy of dietary diversity and multiple micronutrient intake among WRA in most LMICs. Effective measures involving improving dietary diversity, food fortification with micronutrients, and supplementation programs could help improve the dietary quality and intake of optimal micronutrients by women in LMICs.

Firm-Level and Public-Sector Costs Make Small-Scale Maize Flour Fortification Challenging in Uganda

BACKGROUND

Maize flour in Uganda is milled by hundreds of enterprises, mostly small- (5-20 metric tons [MT]/day) and micro-scale (<5 MT/day) mills or firms. A mandatory maize flour fortification program exists for medium-scale mills (>20 MT/day) and policymakers are considering including smaller-scale millers.

OBJECTIVE

We estimated the private and public costs of maize flour fortification at different scales and explored their implications for extending the mandatory fortification to include smaller-scale mills.

METHODS

We used secondary data on the structure of the maize flour market and primary data on milling and fortification costs to estimate mill and regulatory costs at 3 scales of flour production: micro, small, and medium.

RESULTS

For micro-, small-, and medium-size operations, respectively, operational costs of fortification were US$13, US$9, and US$7 per metric ton (MT) of maize flour, which represented 20%, 16%, and 16% of annual operating costs, and the ratio of fortification equipment cost to mill equipment costs was higher for micro-scale mills (2.7) than for small- (0.38) and medium-scale (0.54) maize mills. Governmental regulatory costs rise if smaller-scale mills are included due to the increased number of facility inspections.

CONCLUSIONS

Fortification and regulatory costs increase as production scale decreases. Up-front capital costs of fortification would be daunting for micro- and small-scale mills. Medium-scale mills, which supply social protection programs, might be able to manage fortification costs and other challenges. Decision-makers should consider all costs and cost burdens, and the realities of enforcement capabilities before expanding fortification programs to include smaller-scale operations.

Fortified edible oils in Bangladesh: A study on vitamin A fortification and physicochemical properties

Food fortification has always been an effective and proven practice for eradicating various nutrient deficiencies in Bangladesh. This study investigated different quality parameters of three types (soybean, sunflower, and palm) of extensively consumed fortified edible oils in Bangladesh. Vitamin A analysis has shown that the vitamin A fortification level of most of the oil brands (73 %) did not comply with the Bangladesh Standard and Testing Institution (BSTI) standards (1.5-3.0 mg/100 g). Vitamin A contents of soybean, sunflower, and palm oil brands ranged from 0.13 to 2.06, 0.92-1.34, and 0.99-1.31 mg/100 g, respectively. Inter-brand values of vitamin A were also significantly different (p < 0.05). The majority of the samples were found to be within the acceptable ranges of Codex and BSTI, taking into account the significant chemical quality parameters for soybean, sunflower, and palm oil, such as acid value (0.31-0.93, 0.31-0.56, 0.39-0.81 mg KOH/g), free fatty acid (0.15-0.46, 0.15-0.28, 0.2-0.41 %), saponification (188.64-196.35, 186.53-188, 197.05-199.86 mg KOH/g), and peroxide values (0.06-2.9, 0.65-1.58, 1.35-1.75 meq O2/kg) respectively. All the brands' physical quality parameters (density, specific gravity, pH, viscosity, smoke point, color, and RI) complied with Codex standards. Various physical and chemical quality parameters were analyzed for significant correlations at 0.01 and 0.05 levels of significance. Remarkably, significant correlations were found between vitamin A and peroxide value (p < 0.01), iodine value and viscosity (p < 0.01), saponification value and viscosity (p < 0.01), pH and viscosity (p < 0.01), and saponification value and pH (p < 0.05). In conclusion, although the vitamin A status of most of the fortified edible oil brands was poor, the key quality indicators (except iodine value) of most of the oils were within the Codex and BSTI standard limits and were acceptable for human consumption.

Prevalence of Vitamin A Deficiency in Children Aged 6 to 17 Years - Western and Central Rural Areas, China, 2012-2021

What is already known about this topic?

Vitamin A deficiency (VAD) is a leading global nutritional concern, ranking among the top four major nutritional deficiencies worldwide. The prevalence of VAD is unevenly distributed across various regions, both within China and globally.

What is added by this report?

The report adds valuable insights into the vitamin A nutritional status of rural students aged 6-17 years who participated in the Nutrition Improvement Programme for Rural Compulsory Education Students (NIPRCES). Over the decade from 2012 to 2021, there was a modest improvement in vitamin A status. The prevalence of VAD and sub-clinical VAD (SVAD) declined as the students aged. Throughout the majority of the survey years, the incidence of VAD was higher among males and western regions compared to females and central regions, respectively.

What are the implications for public health practice?

A comprehensive approach, incorporating dietary diversification, nutrition education, and food fortification, should be implemented to prevent VAD and SVAD especially in males, younger children and children in western areas.

Folic acid: friend or foe in cancer therapy

Folic acid plays a crucial role in diverse biological processes, notably cell maturation and proliferation. Here, we performed a literature review using articles listed in electronic databases, such as PubMed, Scopus, MEDLINE, and Google Scholar. In this review article, we describe contradictory data regarding the role of folic acid in cancer development and progression. While some studies have confirmed its beneficial effects in diminishing the risk of various cancers, others have reported a potential carcinogenic effect. The current narrative review elucidates these conflicting data by highlighting the possible molecular mechanisms explaining each point of view. Further multicenter molecular and genetic studies, in addition to human randomized clinical trials, are necessary to provide a more comprehensive understanding of the relationship between folic acid and cancer.

Lethal Neural Tube Defects: Reports of Anencephaly and Craniorachischisis Cases and Literature Review

Neural tube defects are serious birth defects of the central nervous system that result from a multifaceted disruption of normal embryogenesis of the nervous system. Although largely preventable, they nonetheless pose a serious threat to global morbidity, disability, mortality, and financial expenses. Despite this, it has been neglected and has only been the subject of limited research until recently. Furthermore, surveillance efforts for neural tube defects remain limited, and no decline in defects has been documented in less developed countries. Here, we report two cases of craniorachischisis and one case of discordant twins for anencephaly. Moreover, the relevant works of literature that are necessary to understand and address this unrelenting phenomenon are provided.

Benefits and Harms of Edible Vegetable Oils and Fats Fortified with Vitamins A and D as a Public Health Intervention in the General Population: A Systematic Review of Interventions

This systematic review aims to assess whether edible vegetable oils and fats fortified with vitamin A and/or D are effective and safe in improving vitamin intake and ameliorating deficiency states in the general population. In November 2022, we systematically searched MEDLINE, Cochrane CENTRAL, Scopus, Global Index Medicus, ClinicalTrials.gov, and WHO ICTRP (International Clinical Trials Registry Platform) for randomized controlled trials (RCT) and non-randomized studies of interventions (NRSI) investigating the fortification of edible vegetable oils and fats with either vitamin A or vitamin D or both as compared to the same vegetable oils and/or fats without vitamin A and D fortification or no interventions, in the general population, without age restriction. We assessed the methodological quality of included RCTs using Cochrane's risk of bias tool 2.0 and of NRSIs using ROBINS-I tool. We performed random-effects meta-analysis and assessed certainty of evidence using GRADE. We included eight studies. Available evidence showed no significant effect of fortification with vitamin A on serum retinol levels (RCTs: MD 0.35 µmol/L, 95% CI -0.43 to 1.12; two trials; 514 participants; low-certainty evidence; CCTs: MD 0.31 µmol/L, 95% CI -0.18 to 0.80; two trials; 205 participants; very low-certainty evidence) and on subclinical vitamin A deficiency. Low-certainty evidence showed no effect of vitamin D fortification on serum 25-hydroxy vitamin D concentration (MD 6.59 nmol/L, 95% CI -6.89 to 20.07; one trial; 62 participants). In conclusion, vitamin A-fortified vegetable oils and fats may result in little to no difference in serum retinol levels in general populations. The dose of vitamin A used in the trials may be safe but may not be sufficient to reduce subclinical vitamin A deficiency. Further, the evidence suggests that vitamin D fortification results in little to no difference in serum 25-hydroxy vitamin D concentration. Several aspects of providing fortified oils and fats to the general population as a public health intervention should be further investigated, including optimal fortification dose, effects on vitamin D deficiency and its clinical symptoms and potential adverse effects.

National Diet and Nutrition Survey data reveal a decline in folate status in the United Kingdom population between 2008 and 2019

BACKGROUND

Folate is essential for healthy growth and development. Fortification of foods with folic acid can improve folate status and reduce risk of neural tube defects (NTD). Following concern around folate status in the United Kingdom, the United Kingdom government announced in 2021 the intention to introduce mandatory folic acid fortification.

OBJECTIVE

This study aimed to describe folate status in the United Kingdom population prior to the implementation of mandatory folic acid fortification of non-whole wheat (non-wholemeal) flour and to assess trends in folate status, including in females of reproductive age (FRA).

METHODS

Data were from the United Kingdom National Diet and Nutrition Survey Rolling Program (2008-2019), a cross-sectional, nationally representative survey of children and adults aged 1.5+ (n = 5792 with folate result). Serum folate concentration was measured by liquid chromatography tandem mass spectrometry (LC-MS/MS) and red blood cell (RBC) folate concentration by microbiological assay. Concentration data were compared against method-specific cut-offs and thresholds, and relationships were explored against demographic and lifestyle characteristics.

RESULTS

RBC and serum folate concentration significantly decreased by ∼3 percentage points per year between 2008 and 2019 in all age/sex groups. Prevalence of deficiency (RBC folate < 305 nmol/L) was highest in children aged 11 to 18 y (17% in 2016-2019). The proportion of FRA below the cut-off for increased risk of NTD (RBC folate < 748 nmol/L) increased from 69% to 89% between 2008 and 2019. Ethnicity, smoking status, and income were significant determinants of RBC and serum folate concentrations.

CONCLUSIONS

These data reveal a decline in population folate status in the United Kingdom between 2008 and 2019 and a high prevalence of folate deficiency. A high proportion of FRA had RBC folate concentrations below the cut-off for increased risk of NTD. These data provide information on folate status in a population not currently exposed to mandatory folic acid fortification and are essential to model and assess its impact.

Micronutrient gaps during the complementary feeding period in seven countries in Southeast Asia: A Comprehensive Nutrient Gap Assessment

The complementary feeding period is a critical stage of child development when micronutrient needs are high and challenging to meet. Understanding if specific micronutrient gaps exist during this period is critical for effective programming. A Comprehensive Nutrient Gap Assessment (CONGA) was conducted in seven countries in Southeast Asia to estimate gaps in micronutrients commonly lacking in the diets of children aged 6-23 months and to establish the certainty of available evidence for each identified gap. Sixty-eight evidence sources were identified during this analysis, and 310 micronutrient-specific data points were identified across all seven countries. Data points varied in recency, representativeness and evidence type. The CONGA methodology enabled the estimation of a gap burden rating for each micronutrient in each country, as well as a rating of their evidence certainty. Micronutrient gaps were identified in vitamin D, zinc and iron and a potential gap was identified in calcium during the complementary feeding period in the region. Evidence relevant to intake and deficiency of folate, vitamin B12 , thiamine, niacin, vitamin C and vitamin B6 was limited across the region. Proven strategies to address these gaps include increasing the availability and consumption of nutrient-dense foods, micronutrient supplementation, large-scale fortification of staple foods and condiments and point-of-use fortification through multiple micronutrient powders and fortified speciality foods. More recent data on micronutrient availability, intake and deficiency is urgently needed in Southeast Asia.

Approaches to Address the Anemia Challenge

Anemia is a multifactorial condition; approaches to address it must recognize that the causal factors represent an ecology consisting of internal (biology, genetics, and health) and external (social/behavioral/demographic and physical) environments. In this paper, we present an approach for selecting interventions, followed by a description of key issues related to the multiple available interventions for prevention and reduction of anemia. We address interventions for anemia using the following 2 main categories: 1) those that address nutrients alone, and, 2) those that address nonnutritional causes of anemia. The emphasis will be on interventions of public health relevance, but we also consider the clinical context. We also focus on interventions at different stages of the life course, with a particular focus on women of reproductive age and preschool-age children, and present evidence on various factors to consider when selecting an intervention-inflammation, genetic mutations, nutrient delivery, bioavailability, and safety. Each section on an intervention domain concludes with a brief discussion of key research areas.

The role of orphan crops in the transition to nutritional quality-oriented crop improvement

Micronutrient malnutrition is a persisting problem threatening global human health. Biofortification via metabolic engineering has been proposed as a cost-effective and short-term means to alleviate this burden. There has been a recent rise in the recognition of potential that underutilized, orphan crops can hold in decreasing malnutrition concerns. Here, we illustrate how orphan crops can serve as a medium to provide micronutrients to populations in need, whilst promoting and maintaining dietary diversity. We provide a roadmap, illustrating which aspects to be taken into consideration when evaluating orphan crops. Recent developments have shown successful biofortification via metabolic engineering in staple crops. This review provides guidance in the implementation of these successes to relevant orphan crop species, with a specific focus on the relevant micronutrients iron, zinc, provitamin A and folates.

Intergenerational association of gut microbiota and metabolism with perinatal folate metabolism and neural tube defects

Disorders of folic acid metabolism during pregnancy lead to fetal neural tube defects (NTDs). However, the mechanisms still require further investigation. Here, we aim to analyze the brain metabolic profiles of 30 NTDs and 30 healthy fetuses. Our results indicated that low-folate diet during early life played a causal role in cerebral metabolism, especially in lipometabolic disturbance, highlighting the importance of folate in modulating brain development and metabolism. Next, we established a mouse model of NTDs. Interestingly, the differential metabolites are mainly involved in glycerophospholipid metabolism and biosynthesis of unsaturated fatty acids both in human and mice fetal brain. Since intestinal microbes could critically regulate neurofunction via the intestinal-brain axis, we further found the abundances of Firmicutes and Bacteroidetes in the gut of pregnant mice were correlated with the abundances of lipid metabolism related metabolites in the fetal brain. This finding probably reflects the intergenerational microbial-metabolism biomarkers of NTDs.

Implementing micronutrient fortification programs as a potential practical contribution to achieving sustainable diets

Due to sustainability concerns related to current diets and environmental challenges, it is crucial to have sound policies to protect human and planetary health. It is proposed that sustainable diets will improve public health and food security and decrease the food system's effect on the environment. Micronutrient deficiencies are a well-known major public health concern. One-third to half of the world's population suffers from nutrient deficiencies, which have a negative impact on society in terms of unrealised potential and lost economic productivity. Large-scale fortification with different micronutrients has been found to be a useful strategy to improve public health. As a cost-effective strategy to improve micronutrient deficiency, this review explores the role of micronutrient fortification programmes in ensuring the nutritional quality (and affordability) of diets that are adjusted to help ensure environmental sustainability in the face of climate change, for example by replacing some animal-sourced foods with nutrient-dense, plant-sourced foods fortified with the micronutrients commonly supplied by animal-sourced foods. Additionally, micronutrient fortification considers food preferences based on the dimensions of a culturally sustainable diet. Thus, we conclude that investing in micronutrient fortification could play a significant role in preventing and controlling micronutrient deficiencies, improving diets and being environmentally, culturally and economically sustainable.

Prevalence, years lived with disability, and trends in anaemia burden by severity and cause, 1990-2021: findings from the Global Burden of Disease Study 2021

BACKGROUND

Anaemia is a major health problem worldwide. Global estimates of anaemia burden are crucial for developing appropriate interventions to meet current international targets for disease mitigation. We describe the prevalence, years lived with disability, and trends of anaemia and its underlying causes in 204 countries and territories.

METHODS

We estimated population-level distributions of haemoglobin concentration by age and sex for each location from 1990 to 2021. We then calculated anaemia burden by severity and associated years lived with disability (YLDs). With data on prevalence of the causes of anaemia and associated cause-specific shifts in haemoglobin concentrations, we modelled the proportion of anaemia attributed to 37 underlying causes for all locations, years, and demographics in the Global Burden of Disease Study 2021.

FINDINGS

In 2021, the global prevalence of anaemia across all ages was 24·3% (95% uncertainty interval [UI] 23·9-24·7), corresponding to 1·92 billion (1·89-1·95) prevalent cases, compared with a prevalence of 28·2% (27·8-28·5) and 1·50 billion (1·48-1·52) prevalent cases in 1990. Large variations were observed in anaemia burden by age, sex, and geography, with children younger than 5 years, women, and countries in sub-Saharan Africa and south Asia being particularly affected. Anaemia caused 52·0 million (35·1-75·1) YLDs in 2021, and the YLD rate due to anaemia declined with increasing Socio-demographic Index. The most common causes of anaemia YLDs in 2021 were dietary iron deficiency (cause-specific anaemia YLD rate per 100 000 population: 422·4 [95% UI 286·1-612·9]), haemoglobinopathies and haemolytic anaemias (89·0 [58·2-123·7]), and other neglected tropical diseases (36·3 [24·4-52·8]), collectively accounting for 84·7% (84·1-85·2) of anaemia YLDs.

INTERPRETATION

Anaemia remains a substantial global health challenge, with persistent disparities according to age, sex, and geography. Estimates of cause-specific anaemia burden can be used to design locally relevant health interventions aimed at improving anaemia management and prevention.

FUNDING

Bill & Melinda Gates Foundation.

Global Coverage of Mandatory Large-Scale Food Fortification Programs: A Systematic Review and Meta-Analysis

Food fortification with micronutrients is widely implemented to reduce micronutrient deficiencies and related outcomes. Although many factors affect the success of fortification programs, high population coverage is needed to have a public health impact. We aimed to provide recent global coverage estimates of salt, wheat flour, vegetable oil, maize flour, rice, and sugar among countries with mandatory fortification legislation. The indicators were the proportion of households consuming the: food, fortifiable food (that is, industrially processed), fortified food (to any extent), and adequately fortified food (according to national or international standards). We estimated the number of individuals reached with fortified foods. We systematically retrieved and reviewed all applicable evidence from: published reports and articles from January 2010 to August 2021, survey lists/databases from key organizations, and reports/literature received from key informants. We analyzed data with R statistical package using random-effects meta-analysis models. An estimated 94.4% of households consumed salt, 78.4% consumed fortified salt (4.2 billion people), and 48.6% consumed adequately fortified salt in 64, 84, and 31 countries, respectively. Additionally, 77.4% of households consumed wheat flour, 61.6% consumed fortifiable wheat flour, and 47.1% consumed fortified wheat flour (66.2 million people) in 15, 8, and 10 countries, respectively, and 87.0% consumed vegetable oil, 86.7% consumed fortifiable oil, and 40.1% consumed fortified oil (123.9 million people) in 10, 7, and 5 countries, respectively. Data on adequately fortified wheat flour and vegetable oil and coverage indicators for maize flour, rice, and sugar were limited. There are major data gaps on fortification coverage for most foods except salt. All countries with mandatory fortification programs should generate and use more coverage data to assess program performance and adjust programs as needed to realize their potential to reduce micronutrient deficiencies (PROSPERO CRD42021269364).

Investigating the pathways from preconception care to preventing maternal, perinatal and child mortality: A scoping review and causal loop diagram

In recent years, there has been a growing recognition that developing preconception care provides an opportunity to significantly reduce maternal and child mortality and morbidity. This involves targeting multiple risk factors through a large array of medical, behavioural and social interventions. In this study, we created a Causal Loop Diagram (CLD) to describe several pathways by which a set of preconception interventions may lead to women's improved health and better pregnancy outcomes. The CLD was informed by a scoping review of meta-analyses. It summarises evidence on the outcomes and interventions related to eight preconception risk factors. The authors reviewed literature from two databases (PubMed and Embase) and used the framework developed by Arksey and O'Malley. The CLD includes 29 constructs categorised into five different levels (mortality, causes of death, preconception risk factors, intermediate factors, interventions or policies). The model indicates interconnections between five sub-systems and highlights the role of preventing early and rapidly repeated pregnancies, as well as optimising women's nutritional status in the preconception period. It also shows the prevention of preterm birth as a privileged route for lowering child mortality and morbidity. The CLD demonstrates the potential benefits of strategies that address multiple preconception risk factors simultaneously and can be used as a tool to promote the integration of preconception care into efforts to prevent maternal and child mortality. With further improvements, this model could serve as a basis for future research on the costs and benefits of preconception care.

Plant-Based Dairy Alternatives Contribute to a Healthy and Sustainable Diet

Plant-based foods are increasing in popularity as more and more people are concerned about personal and planetary health. The consumption of plant-based dairy alternatives (PBDAs) has assumed a more significant dietary role in populations shifting to more sustainable eating habits. Plant-based drinks (PBDs) made from soya and other legumes have ample protein levels. PBDs that are appropriately fortified have adequate levels of important vitamins and minerals comparable to dairy milk. For the PBDs examined, the greenhouse gas emissions were diminished by 59-71% per 250 mL, and the land use and eutrophication impact was markedly less than the levels displayed by dairy milk. The water usage for the oat and soya drinks, but not rice drinks, was substantially lower compared to dairy milk. When one substitutes the 250 mL serving of dairy milk allowed within the EAT Lancet Planetary Health Diet for a fortified plant-based drink, we found that the nutritional status is not compromised but the environmental footprint is reduced. Combining a nutrient density score with an environmental index can easily lead to a misclassification of food when the full nutrition profile is not utilized or only a selection of environmental factors is used. Many PBDAs have been categorized as ultra-processed foods (UPFs). Such a classification, with the implied adverse nutritional and health associations, is inconsistent with current findings regarding the nutritional quality of such products and may discourage people from transitioning to a plant-based diet with its health and environmental advantages.

Micronutrients/miRs/ATP networking in mitochondria: Clinical intervention with ferroptosis, cuproptosis, and calcium burden

The mitochondrial electron transport chain (mtETC) requires mainly coenzyme Q10 (CoQ10), copper (Cu2+), calcium (Ca2+), and iron (Fe2+) ions for efficient ATP production. According to cross-sectional research, up to 50% of patients with micronutrient imbalances have been linked to oxidative stress, mitochondrial dysfunction, reduced ATP production, and the prognosis of various diseases. The condition of ferroptosis, which is caused by the downregulation of CoQ10 and the activation of non-coding micro RNAs (miRs), is strongly linked to free radical accumulation, cancer, and neurodegenerative diseases. The entry of micronutrients into the mitochondrial matrix depends upon the higher threshold level of mitochondrial membrane potential (ΔΨm), and high cytosolic micronutrients. The elevated micronutrient in the mitochondrial matrix causes the utilization of all ATP, leading to a drop in ATP levels. Mitochondrial calcium uniporter (MCU) and Na+/Ca2+ exchanger (NCX) play a major role in Ca2+ influx in the mitochondrial matrix. The mitochondrial Ca2+ overload is regulated by specific miRs such as miR1, miR7, miR25, miR145, miR138, and miR214, thereby reducing apoptosis and improving ATP production. Cuproptosis is primarily brought on by increased Cu+ build-up and mitochondrial proteotoxic stress, mediated by ferredoxin-1 (FDX1) and long non-coding RNAs. Cu importers (SLC31A1) and exporters (ATP7B) influence intracellular Cu2+ levels to control cuproptosis. According to literature reviews, very few randomized micronutrient interventions have been carried out, despite the identification of a high prevalence of micronutrient deficiencies. In this review, we concentrated on essential micronutrients and specific miRs associated with ATP production that balance oxidative stress in mitochondria.

Global strategies for the prevention of neural tube defects through the improvement of folate status in women of reproductive age

INTRODUCTION

Neural tube defects represent a global public health problem, mainly in countries where effective prevention strategies are not yet in place. The global prevalence of neural tube defects is estimated at 18.6/10,000 (uncertainty interval: 15.3-23.0) live births, where ~ 75% of cases result in under-five mortality. Most of the mortality burden is in low- and middle-income countries. The main risk factor for this condition is insufficient folate levels in women of reproductive age.

METHODS

This paper reviews the extent of the problem, including the most recent global information on folate status in women of reproductive age and the most recent estimates of the prevalence of neural tube defects. Additionally, we provide an overview of the available interventions worldwide to reduce the risk of neural tube defects by improving folate status in the population, including dietary diversification, supplementation, education, and fortification.

RESULTS

Large-scale food fortification with folic acid is the most successful and effective intervention to reduce the prevalence of neural tube defects and associated infant mortality. This strategy requires the coordination of several sectors, including governments, the food industry, health services providers, the education sector, and entities that monitor the quality of the service processes. It also requires technical knowledge and political will. An international collaboration between governmental and non-governmental organizations is essential to succeed in saving thousands of children from a disabling but preventable condition.

DISCUSSION

We propose a logical model for building a national-level strategic plan for mandatory LSFF with folic acid and explain the actions needed for promoting sustainable system-level change.

Integrating and coordinating programs for the management of anemia across the life course

Anemia is a major global public health concern with a complex etiology. The main determinants are nutritional factors, infection and inflammation, inherited blood disorders, and women's reproductive biology, but the relative role of each varies between settings. Effective anemia programming, therefore, requires evidence-based, data-driven, contextualized multisectoral strategies, with coordinated implementation. Priority population groups are preschool children, adolescent girls, and pregnant and nonpregnant women of reproductive age. Opportunities for comprehensive anemia programming include: (i) bundling interventions through shared delivery platforms, including antenatal care, community-based platforms, schools, and workplaces; (ii) integrating delivery platforms to extend reach; (iii) integrating anemia and malaria programs in endemic areas; and (iv) integrating anemia programming across the life course. Major barriers to effective anemia programming include weak delivery systems, lack of data or poor use of data, lack of financial and human resources, and poor coordination. Systems strengthening and implementation research approaches are needed to address critical gaps, explore promising platforms, and identify solutions to persistent barriers to high intervention coverage. Immediate priorities are to close the gap between access to service delivery platforms and coverage of anemia interventions, reduce subnational coverage disparities, and improve the collection and use of data to inform anemia strategies and programming.

A generic theory of change-based framework with core indicators for monitoring the effectiveness of large-scale food fortification programs in low- and middle-income countries

Large-scale food fortification (LSFF) programs are widely implemented in low- and middle-income countries (LMIC) to alleviate micronutrient deficiencies. However, these programs may not achieve the desired impact due to poor design or bottlenecks in program implementation. Monitoring and evaluation (M&E) frameworks and a set of agreed indicators can help to benchmark progress and to strengthen the evidence-base of effectiveness in a standardized way. We aimed to formulate recommendations towards core indicators for evaluating the effectiveness of LSFF programs with their associated metrics, methods, and tools (IMMT). For this, we used a multi-method iterative approach, including a mapping review of the literature, semi-structured interviews with international experts, compilation of a generic Theory of Change (ToC) framework for LSFF program delivery, and selection of IMMT for M&E of LSFF programs at key stages along the ToC delivery framework. Lastly, we conducted exploratory, qualitative interviews with key informants in Nigeria to explore experiences and perceptions related to the implementation of LSFF programs in Nigeria's context, and their opinion towards the proposed set of core IMMT. The literature search resulted in 14 published and 15 grey literature documents, from which we extracted a total of 41 indicators. Based on the available literature and interviews with international experts, we mapped a ToC delivery framework and selected nine core indicators at the output, outcome and impact level for M&E of the effectiveness of LSFF programs. Key informants in Nigeria revealed that the main bottlenecks for implementation of the proposed IMMT are related to the lack of technical capacity, equipment, laboratory infrastructure, and financial resources. In conclusion, we propose a set of nine core indicators for enabling comprehensive M&E of the effectiveness of LSFF programs in LMIC. This proposed set of core indicators can be used for further evaluation, harmonization and integration in national and international protocols for M&E of LSFF programs.

Aligning the Epidemiology of Malnutrition with Food Fortification: Grasp Versus Reach

Large-scale food fortification (LSFF) has been recognized as one of the most cost-effective interventions to improve the intake of vitamins and minerals and decrease the burden of micronutrient deficiency. Indeed, the simple addition of micronutrients to staple foods, such as wheat, maize and rice, or condiments, including salt and bouillon, has tremendous potential to impact malnutrition. However, most LSFF programs have been poorly designed and have not taken into consideration critical inputs, including current levels of nutrient inadequacy and per capita consumption of different food vehicles when deciding which nutrients to add and at what concentrations. LSFF programs, like some other nutrition interventions, also tend to have low coverage and reach and lack monitoring to measure this and course correct. These program design flaws have resulted in limited effectiveness and have made it difficult to determine how best to harmonize LSFF with other interventions to reduce micronutrient deficiencies, including efforts to enhance dietary diversity, biofortification and supplementation. Furthermore, LSFF has often been touted as a population-based intervention, but in fact has heterogenous effects among sub-groups, particularly those with limited access to or inability to afford fortified foods, as well as those with higher physiological requirements, such as pregnant and lactating women. This article focuses on these limitations and the concerted efforts underway to improve the collection, analysis, and use of data to better plan LSFF programs, track implementation, and monitor coverage and impact. This includes a more sophisticated secondary analysis of existing data, innovations to increase the frequency of primary data collection and programmatically relevant visualizations of data of sub-national estimates. These improvements will enable better use of data to target resources and programmatic efforts to reach those who stand to benefit most from fortification.

Folate deprivation induced neuroinflammation impairs cognition

Nutritional status is associated with many neurocognitive diseases. Folate is one of the micronutrients, and its deficiency is associated with clinical outcomes of neurological diseases. Nevertheless, molecular mechanism behind the folate deficiency induced neurological disorders are not well-known. We have hypothesized that folate-deficiency is a cardinal determinant responsible for manifestation of cognitive impairment through inflammation mediated neurodegenerative pathologies. Objective of the current study was to assess whether folate deficiency is associated with cognitive dysfunction or is merely an epiphenomenon and to identify the underlying mechanisms. We developed folate insufficient zebrafish model through intra-peritoneal treatment of methotrexate. T-maze test was carried to assess the spatial learning and memory of the fish. Higher latency of the folate-deprived zebrafishes in the T-maze test is a reflection of altered cognition. This result is supported by declined levels of dopamine and serotonin, neurotransmitters linked with learning and memory. Elevated IL-6 and CRP in peripheral blood, along with increased expression of NF-ĸB in brain indicates manifestation of neuroinflammation. Indeed, together with upregulation of maptb gene it can be implied that folate deficiency acts as a risk factor for neurodegeneration in the form of tauopathies. Furthermore, diminished localisation of synaptopodin, a protein linked to neural plasticity, suggests that neuroinflammation caused by folate deprivation hampers the plasticity of brain. Histological analysis of brain revealed the development of histopathological features including spongiform degeneration and neuronal loss in folate deprived condition. We thus conclude that folate deficiency results in NF-ĸB activation, which through multiple processes mediated by neuroinflammation could lead to cognitive decline.

Micronutrient intake of children in Ghana and Benin: Estimated contribution of diet and nutrition programs

We estimated how micronutrient needs of young children, aged 6-24 months were covered by the standard (traditional) diets in Ghana and Benin, and the contributions of partial breastfeeding and national nutrition programs aimed at improving micronutrient status to overall micronutrient intakes. Estimates of micronutrient intake from standard diets were based on previous surveys, using the food composition table of West Africa (INFOOD). Recommended micronutrient intakes were based on World Health Organization recommendations. Children were grouped in three age groups (6-8, 9-12, and 13-24 months) to capture the changing dynamics of the complementary feeding period. As expected, from 6 months of age onwards, breastmilk didn't cover the micronutrient needs. The standard diets contributed only minimal to micronutrient intakes of children ranging from 0% to 37% of recommended intakes for Ca, Fe, Zn, vitamin A, vitamin D and iodine depending on the micronutrient considered. The contribution of mass (bio)-fortification programs to the coverage of micronutrient needs varied widely, depending on the staple food considered and the country, but overall did not allow to fill the gap in micronutrient needs of children except for vitamin A in some contexts. In contrast, consumption of voluntary fortified complementary food, especially formulated for the needs in this age groups, contributed substantially to overall micronutrient intake and could fill the gap for several micronutrients. The development of young child-targeted programs including micronutrient-dense foods, associated with interventions to increase the diet diversity and meal frequency, could significantly improve micronutrients intakes of children in both Ghana and Benin.

Assessment of Heme and Non-Heme Iron Intake and Its Dietary Sources among Adults in Armenia

Adequate dietary iron (Fe) intake is crucial for preventing Fe-deficient anemia, a recognized global public health concern which is important in Armenia. This study aimed to analyze the intake of Fe, both heme (from animal tissues) and non-heme (more prevalent, but less efficiently absorbed), as well as the Fe dietary sources, among adults in a representative national sample in Armenia. The study was conducted on 1400 individuals aged 18–80 and above, who were enrolled from all regions of Armenia. The Fe intake was assessed through a 24 h dietary recall survey, while Fe occurrence was determined through atomic absorption spectrophotometry (AAS). The results showed a high proportion of adults with a Fe intake lower than the average requirements set by EFSA (65%, 80% and 85% of males, total females and females at fertile age, respectively). Main Fe sources were bread, fruits and vegetables; heme Fe accounted only for <5% of total Fe intake. Compared to males, females had a lower intake of all forms of Fe (p < 0.05). Significant differences were observed in the intake of different forms of Fe between regions (p < 0.05), while the age-group 36–55 years had higher intakes of total Fe. Our data call for comprehensive nutritional security strategies in order to reduce iron deficiency in Armenia, that represents a public health concern.

Dietary diversity and micronutrients adequacy among the women of reproductive age at St. Martin's island in Bangladesh

Minimum dietary diversity for women, an important dimension of diet quality, has been widely used as a proxy indicator for micronutrient adequacy. In low- and middle-income countries (LMICs), women of reproductive age (WRA) particularly are at high risk of inadequate micronutrient intake resulting from poor diversified diets. Therefore, the present study aimed to assess dietary diversity and micronutrients adequacy in the diets of WRA of St. Martin's island, along with their socio-economic determinants. A cross-sectional study was conducted on a representative sample of 201 WRA living at St. Martin's island. Utilizing the Estimated Average Requirement (EAR) cut-point approach, the adequacy of micronutrient intake was evaluated from observed 24-h recall dietary data. The recent guideline of FAO was employed to evaluate Minimum Dietary Diversity for Women (MDD-W). Binary logistic regression and multiple linear regression analyses were performed to identify socio-economic determinants of MDD-W and micronutrients adequacy. The mean (SD) dietary diversity score was 4.25 (1.17) and about 40.3% of the participants met the MDD-W cut-off. Starchy staples (100%), meat/poultry/fish (87%), and other vegetables (79%) were consumed more frequently, while, the least reported food groups were dairy (2%), nuts and seeds (11%), and vitamin A-rich fruits and vegetables (11%). Except for Niacin, intake of all micronutrients was inadequate, with an inadequacy prevalence of 36-100%. Educational level, and decision-making role of women were significantly related to their dietary diversity. On the other hand, age, decision-making role, and MDD-W were important determinants of micronutrient adequacy. In conclusion, the WRA of St. Martin's island consumed neither a sufficient amount of micronutrients nor an adequate diversity of foods. In addition, several socio-economic components are linked with dietary diversity and micronutrient adequacy. Therefore, attention is needed to decide on the best strategies to improve the quality of diet and dietary diversity for WRA in this setting.

Salt-Containing Recipes in Popular Magazines with the Highest Circulation in the United States Do Not Specify Iodized Salt in the Ingredient List

Iodine deficiency is a public health problem in the US, with the iodine status of women of reproductive age decreasing in recent years. This may be attributable to voluntary salt iodization in the US. Magazines, a common source of recipes and nutritional information, may influence salt use and iodine intake. The aim of this study is to assess whether the magazines with the highest circulation in the US include recipes that contain salt and, if so, whether they specify "iodized salt" in the recipes. Recipes in eight of the top ten magazines by circulation in the US were examined. Standardized information was collected on the presence and type of salt in recipes in the last 12 issues reviewed per magazine. About 73% of the 102 issues reviewed contained recipes. A total of 1026 recipes were surveyed for salt; 48% of the recipes listed salt as an ingredient. None of the 493 recipes containing salt specified iodized salt as the type of salt to be used. About half of the recipes in the last 12 issues of popular magazines published in the US included salt in the ingredient list; however, none recommend the use of iodized salt. There is potential for editorial changes among magazines to call for iodized salt in recipes, which may further prevent iodine deficiency in the US.

National Mandatory Grain Fortification Legislation Decreases Anemia Prevalence among Nonpregnant Women of Reproductive Age: Findings from Multiple Demographic and Health Surveys

BACKGROUND

Two billion people are affected by anemia globally, mostly including women of reproductive age (WRA) and those residing in low- and middle-income countries (LMICs). Large national population-representative studies examining the impact of national grain fortification policies on the prevalence of anemia among WRA are lacking from recent years.

OBJECTIVES

We aimed to determine whether mandatory national grain fortification policies reduce the prevalence of anemia among nonpregnant WRA.

METHODS

We examined national food fortification policy characteristics from the Global Fortification Data Exchange (GFDx) database and anemia prevalence data from the Demographic and Health Surveys (DHSs). In total, 21 LMICs, with and without national grain fortification policies, completing ≥2 DHSs between 2000 and 2018, met study eligibility. We applied the difference-in-differences approach to compare changes in the prevalence of anemia among WRA in 10 countries with and 11 countries without fortification between each DHS year. Odds ratios (ORs) and average marginal effects, along with 95% confidence intervals (CIs) were calculated, adjusting for individual-, household-, and country-level factors.

RESULTS

Our analytic study sample included 96,334 and 874,984 WRA in countries with and without fortification, respectively. Overall, countries with fortification showed 27% decreased odds of anemia (adjusted OR: 0.73; 95% CI: 0.63, 0.85) and a 7.47-percentage-point decrease in the mean anemia prevalence (average marginal effect: -7.47; 95% CI: -11.03, -3.92) from the pre- to the postfortification period, compared with countries without fortification, after controlling for selected individual-, household-, and country-level factors.

CONCLUSIONS

Our findings, using nationally representative DHS data and applying a recommended analytic method to measure policy effectiveness, suggest significant reductions in anemia prevalence in WRA in countries with mandatory grain fortification compared with those without. Implementing national mandatory grain fortification in LMICs would effectively reduce anemia resulting from micronutrient deficiencies among WRA.

Impact Investing Holds Promise for Nutrition If Guided by Evidence

There is a widely recognized need to increase funding available for improving nutrition in low- and middle-income countries and to move beyond traditional grants from development agencies and private foundations. This includes the so-called innovative financing approaches, such as impact investment (i.e., investing with the intent to generate positive social impact). Impact investment is no substitute for much-needed public funding to support direct nutrition interventions, but such approaches could make sense where supporting nutrition entails a "business case" that could create profit for a business-thus fostering the positive returns needed by investors. This includes some food-based approaches, as most households purchase food from for-profit companies and entrepreneurs. Investment in firms that produce nutritious foods for local markets could be profitable and-if it were to improve food affordability, accessibility, or desirability-could help improve diet quality. In this Perspective, we describe these innovative financing mechanisms and discuss their potential for supporting nutritious foods. We note that doing so would require a simple yet evidence-based approach to screening nutritious foods for potential investment, and we describe our experience operationalizing this through a novel nutrition impact investment mechanism: the Nutritious Foods Financing Facility. We conclude by highlighting remaining gaps to explore the potential of impact investment in nutrition and what the nutrition community can do to help fill them-and to mitigate the risk of such approaches being applied in ways that do not lead to positive social impact for nutrition.

Maternal Periconceptional Folic Acid Supplementation and DNA Methylation Patterns in Adolescent Offspring

BACKGROUND

Folate, including the folic acid form, is a key component of the one-carbon metabolic pathway used for DNA methylation. Changes in DNA methylation patterns during critical development periods are associated with disease outcomes and are associated with changes in nutritional status in pregnancy. The long-term impact of periconceptional folic acid supplementation on DNA methylation patterns is unknown.

OBJECTIVES

To determine the long-term impact of periconceptional folic acid supplementation on DNA methylation patterns, we examined the association of the recommended dosage (400 μg/d) and time period (periconceptional before pregnancy through first trimester) of folic acid supplementation with the DNA methylation patterns in the offspring at age 14-17 y compared with offspring with no supplementation.

METHODS

Two geographic sites in China from the 1993-1995 Community Intervention Program of folic acid supplementation were selected for the follow-up study. DNA methylation at 402,730 CpG sites was assessed using saliva samples from 89 mothers and 179 adolescents (89 male). The mean age at saliva collection was 40 y among mothers (range: 35-54 y) and 15 y among adolescents (range: 14-17 y). Epigenome-wide analyses were conducted to assess the interactions of periconceptional folic acid exposure, the 5,10-methylenetetrahydrofolate reductase (MTHFR)-C677T genotype, and epigenome-wide DNA methylation controlling for offspring sex, geographic region, and background cell composition in the saliva.

RESULTS

In the primary outcome, no significant differences were observed in epigenome-wide methylation patterns between adolescents exposed and those non-exposed to maternal periconceptional folic acid supplementation after adjustment for potential confounders [false discovery rate (FDR) P values < 0.05]. The MTHFR-C677T genotype did not modify this lack of association (FDR P values < 0.05).

CONCLUSIONS

Overall, there were no differences in DNA methylation between adolescents who were exposed during the critical developmental window and those not exposed to the recommended periconceptional/first-trimester dosage of folic acid.

Thiamine deficiency in pregnancy and lactation: implications and present perspectives

During pregnancy, many physiologic changes occur in order to accommodate fetal growth. These changes require an increase in many of the nutritional needs to prevent long-term consequences for both mother and the offspring. One of the main vitamins that are needed throughout the pregnancy is thiamine (vitamin B1) which is a water-soluble vitamin that plays an important role in many metabolic and physiologic processes in the human body. Thiamine deficiency during pregnancy can cause can have many cardiac, neurologic, and psychological effects on the mother. It can also dispose the fetus to gastrointestinal, pulmonological, cardiac, and neurologic conditions. This paper reviews the recently published literature about thiamine and its physiologic roles, thiamine deficiency in pregnancy, its prevalence, its impact on infants and subsequent consequences in them. This review also highlights the knowledge gaps within these topics.

Maternal and child nutrition in the Lives Saved Tool: Results of a recent update

Background

The Lives Saved Tool (LiST) is a mathematical modelling tool for estimating the survival, health, and nutritional impacts of scaling intervention coverage in low- and middle-income countries (LMICs). Various nutrition interventions are included in LiST and are regularly (and independently) reviewed and updated as new data emerge. This manuscript describes our latest in-depth review of nutrition evidence, focusing on intervention efficacy, appropriate population-affected fractions, and new interventions for potential inclusion in the LiST model.

Methods

An external advisory group (EAG) was assembled to review evidence from systematic reviews on intervention-outcome (I-O) pairs for women and children under five years of age. GRADE quality was assigned to each pair based on a LiST-specific checklist to facilitate consistent decisions during the consideration. For existing interventions with new information, the EAG was asked to recommend whether to update the default efficacy values and population-affected fractions. For the new interventions, the EAG decided whether there was sufficient evidence of benefit, and in affirmative cases, information on the efficacy and affected fraction values that could be used. Decisions were based on expert group consensus.

Results

Overall, the group reviewed 53 nutrition-related I-O pairs, including 25 existing and 28 new ones. Efficacy and population-affected fractions were updated for seven I-O pairs; three pairs were updated for efficacy estimates only, three were updated for population-affected fractions only; and nine new I-O pairs were added to the model, bringing the total of nutrition-related I-O pairs to 34. Included in the new I-O pairs were two new nutrition interventions added to LIST: zinc fortification and neonatal vitamin A supplementation.

Conclusions

For modelling tools like LiST to be useful, it is crucial to update interventions, efficacy and population-affected fractions as new evidence becomes available. The present updates will enable LiST users to better estimate the potential health, nutrition, and survival benefits of investing in nutrition.

Effects of prenatal nutritional supplements on gestational weight gain in low- and middle-income countries: a meta-analysis of individual participant data

BACKGROUND

Gestational weight gain (GWG) below or above the Institute of Medicine (IOM) recommendations has been associated with adverse perinatal outcomes. Few studies have examined the effect of prenatal nutrient supplementations on GWG in low- and middle-income countries (LMICs).

OBJECTIVES

We aimed to investigate the effects of multiple micronutrient supplements (MMSs) and small-quantity lipid-based nutrient supplements (LNSs) on GWG in LMICs.

METHODS

A 2-stage meta-analysis of individual participant data was conducted to examine the effects of MMSs (45,507 women from 14 trials) and small-quantity LNSs (6237 women from 4 trials) on GWG compared with iron and folic acid supplements only. Percentage adequacy of GWG and total weight gain at delivery were calculated according to the IOM 2009 guidelines. Binary outcomes included severely inadequate (percentage adequacy <70%), inadequate (<90%), and excessive (>125%) GWG. Results from individual trials were pooled using fixed-effects inverse-variance models. Heterogeneity was examined using I2, stratified analysis, and meta-regression.

RESULTS

MMSs resulted in a greater percentage adequacy of GWG [weighted mean difference (WMD): 0.86%; 95% CI: 0.28%, 1.44%; P < 0.01] and higher GWG at delivery (WMD: 209 g; 95% CI: 139, 280 g; P < 0.01) than among those in the control arm. Women who received MMSs had a 2.9% reduced risk of severely inadequate GWG (RR: 0.971; 95% CI: 0.956, 0.987; P < 0.01). No association was found between small-quantity LNSs and GWG percentage adequacy (WMD: 1.51%; 95% CI: -0.38%, 3.40%; P = 0.21). Neither MMSs nor small-quantity LNSs were associated with excessive GWG.

CONCLUSIONS

Maternal MMSs were associated with greater GWG percentage adequacy and total GWG at delivery than was iron and folic acid only. This finding is consistent with previous results on birth outcomes and will inform policy development and local recommendations of switching routine prenatal iron and folic acid supplements to MMSs.

Impact of Nutrition Interventions for Reduction of Anemia in Women of Reproductive Age in Low- and Middle-Income Countries: A Meta-Review

Background

The UN Sustainable Development Goal aims at a 50% reduction of anemia in women of reproductive age (WRA) by 2030. Several nutrition-specific and sensitive interventions are targeted across low- and middle-income countries (LMICs) to reduce anemia.

Objectives

In this meta-review we comprehensively assessed the effectiveness of nutrition-specific and -sensitive interventions on hemoglobin (Hb) and serum ferritin (SF) concentrations and the prevalence of iron deficiency and anemia among WRA, pregnant women, and lactating women from LMICs.

Method

The preparation of the present meta-review followed a double-blinded synthesis process with 3 stages: screening, quality appraisal, and data extraction in Eppi Reviewer. A comprehensive search was performed for systematic reviews (SRs) published between January 2000 and May 2022 using 21 international, national, and regional databases. The methodological quality appraisal of included studies was conducted using the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) checklist.

Results

A total of 23 SRs evaluated the effects of various nutrition-specific interventions included in the final synthesis. The included SRs included analyses of nutrition-specific interventions such as supplementation of the nutrients iron (n = 7), iron and folic acid (n = 4), vitamin A (n = 3), calcium (n = 2), multiple micronutrients (n = 7), and intravenous iron sucrose (n = 2). Also, SRs on fortification of nutrients included multiple micronutrients (n = 6), iron and folic acid (n = 4), and iron (n = 4). Of the 23 SRs, 22 were of high quality. Iron with or without folic acid supplementation and fortification and vitamin A supplementation consistently showed positive effects on either reduction in the prevalence of anemia or iron deficiency and improving the Hb or SF concentrations in WRA and pregnant women from LMICs.

Conclusion

The comprehensive meta-review reported the beneficial effects of iron with or without folic acid, multiple micronutrient supplementation/fortification, and vitamin A supplementation in reducing the prevalence of anemia or iron deficiency and increasing Hb or SF concentrations in WRA from LMICs.

Food fortification strategies to deliver nutrients for the management of iron deficiency anaemia

A rising trend in the global prevalence of anaemia is still prevailing. To combat micronutrient deficiencies, World Health Organisation/Food Agriculture Organisation (2006) guidelines recommended four chief strategies - supplementation, fortification, nutrition education and dietary diversity. Of the four strategies, food fortification has been considered as the most efficacious and economical approach. However, it is the directives themselves that highlight two major bottlenecks associated with conventional fortification - uniform dissemination of the fortifier in food vehicle that mostly include staple foods, and internal and external compliance evaluation of fortification regulations and standards by the producers. As a result, researchers envisaged a new strategy - Food-to-food fortification that complements conventional fortification. This strategy involves fortification of food vehicles with nutrient-rich food-based fortifiers. The major advantage of utilising food-based fortifiers is that they hold the potential of enhancing the bioavailability of the fortified food and providing additional nutrients and thus, resulting in dietary diversification. It also facilitates the utilisation of underutilised crops as food-based fortifiers. Underutilised crops have been recognised as potential beneficial food source accounting to their nutritional, ecological, and fiscal benefits. This review paper delves into the strengths and shortcomings of conventional iron fortification. It delineates the concept of food-to-food fortification, while precisely discussing about the best practices to be followed to address the possible challenges associated with this strategy. It also promotes the utilisation of underutilised iron rich foods to develop fortified foods and avert global food insecurity. Furthermore, it provides a summary of the studies conducted around the world to develop fortified foods using iron compounds and iron-rich foods, and to investigate their efficacy in managing iron deficiency anaemia.

Folic Acid and the Prevention of Birth Defects: 30 Years of Opportunity and Controversies

For three decades, the US Public Health Service has recommended that all persons capable of becoming pregnant consume 400 μg/day of folic acid (FA) to prevent neural tube defects (NTDs). The neural tube forms by 28 days after conception. Fortification can be an effective NTD prevention strategy in populations with limited access to folic acid foods and/or supplements. This review describes the status of mandatory FA fortification among countries that fortify (n = 71) and the research describing the impact of those programs on NTD rates (up to 78% reduction), blood folate concentrations [red blood cell folate concentrations increased ∼1.47-fold (95% CI, 1.27, 1.70) following fortification], and other health outcomes. Across settings, high-quality studies such as those with randomized exposures (e.g., randomized controlled trials, Mendelian randomization studies) are needed to elucidate interactions of FA with vitamin B12 as well as expanded biomarker testing.

Relationship between achieving Sustainable Development Goals and promoting optimal care and prevention of birth defects globally

Birth defects affect eight million newborns annually worldwide. About 8% of global under-5 mortality is attributable to birth defects. The United Nations (UN) Sustainable Development Goals (SDGs) have set 17 global goals for human growth and development to be achieved by 2030 using multi-sectorial approaches. The third goal (SDG-3) focuses on ensuring healthy lives and promoting well-being; achieving SDG-3 improves birth defects care and prevention. However, we aimed to show how achieving other SDGs also influence optimal care and prevention of birth defects. SDGs focused on poverty reduction, access to nutritious food, universal health coverage, equitable education, gender equality, environment, inclusivity through infrastructure innovation, and strengthening social justice is crucial to addressing social determinants of health for individuals and families affected by birth defects. Understanding birth defects in the context of several relevant SDGs will allow practitioners, researchers, and policymakers to leverage the momentum generated by SDGs and make a case for commitment and allocation of funding and resources for advancing birth defects surveillance, care, and prevention. SDGs are built on principles of equity and social justice and we urge policy-makers to approach birth defects using various SDGs as a catalyst. The synergy between several SDGs helps to optimize birth defect outcomes and prevention. Our effort to present a more comprehensive look at various SDGs and their relationship with birth defects is parallel to several other health advocacy groups conducting a similar mapping exercise, thus bringing to the forefront millions of lives that are impacted by birth defects worldwide.

Large-scale staple food fortification as a complementary strategy to address vitamin and mineral vulnerabilities in India: A critical review

The slow improvement in micronutrient malnutrition globally and in India warrants a need for scaling-up scientifically proven, cost-effective public health interventions. The present review discusses the potential of staple food fortification as a complementary strategy to tackle micronutrient deficiencies, while addressing the current concerns raised regarding its implementation. The review indicates the below par status of current strategies like dietary diversity and supplementation to address multiple micronutrients deficiencies in India and the need for complementary strategies to tackle this problem. Based on systematic reviews and meta-analysis, global and national evidence has identified staple food fortification as a proven and recognized cost-effective solution to address micronutrient deficiencies. The Government of India has shown a strong leadership to promote this proven intervention. Further, the paper addresses the concern that large-scale staple food fortification (LSFF) may lead to excessive nutrient intakes when delivered together with other interventions, e.g., supplementation, dietary diversity, among the same populations. A key message that emerges from this review is that LSFF is safe with current dietary intake and deficiencies and low coverage of other interventions. Given the current situation of food and nutrition insecurity which the COVID-19 pandemic has further exacerbated, and the critical role that nutrition plays in building immunity, it is even more important that health and nutrition of the population, especially vulnerable age groups, is not only safeguarded but also strengthened. LSFF should be implemented without any further delay to reach the most vulnerable segments of the population to reduce the dietary nutrient gap and prevent micronutrient deficiencies. Effective monitoring and regular dietary surveys will help ensure these interventions are being deployed correctly.

Global Neurosurgery in the Context of Global Public Health Practice-A Literature Review of Case Studies

Neurosurgical conditions are a substantial contributor to surgical burden worldwide, with low- and middle-income countries carrying a disproportionately large part. Policy initiatives such as the National Surgical, Obstetrics and Anesthesia Plans and Comprehensive Policy Recommendations for the Management of Spina Bifida and Hydrocephalus in Low-and-Middle-Income countries have highlighted the need for an intersectoral approach, not just at the hospital level but on a large scale encompassing national public health strategies. This article aims to show through case studies how addressing this surgical burden is not limited to the clinical context but extends to public health strategies as well. For example, vitamin B₁₂ and folic acid are micronutrients that, if not at adequate levels, can result in debilitating neurosurgical conditions. In Ethiopia, through coalesced efforts between neurosurgeons and policy makers, the government has made strides in implementing food fortification programs at a national level to address the neurosurgical burden. Traumatic brain injuries (TBIs) are another neurosurgical burden that unevenly affects LMICs. Countries such as Colombia and India have shown the importance of legislation and enforcement, coupled with robust data collection and auditing systems; strong academic advocacy of neurosurgeons can drastically reduce TBIs. Despite the importance of public health efforts in addressing neurosurgical conditions, there is a lack of neurosurgeon involvement in public health and lack of integration of neurosurgical burden in national health planning systems. It is imperative that neurosurgeons advocate for and are included in aspects of public health policy. Neurosurgery does not stop within the bounds of the hospital, and neither should the role of a neurosurgeon.

Fortification of salt with iron and iodine versus fortification of salt with iodine alone for improving iron and iodine status

BACKGROUND

Iron deficiency is an important micronutrient deficiency contributing to the global burden of disease, and particularly affects children, premenopausal women, and people in low-resource settings. Anaemia is a possible consequence of iron deficiency, although clinical and functional manifestations of anemia can occur without iron deficiency (e.g. from other nutritional deficiencies, inflammation, and parasitic infections). Direct nutritional interventions, such as large-scale food fortification, can improve micronutrient status, especially in vulnerable populations. Given the highly successful delivery of iodine through salt iodisation, fortifying salt with iodine and iron has been proposed as a method for preventing iron deficiency anaemia. Further investigation of the effect of double-fortified salt (i.e. with iron and iodine) on iron deficiency and related outcomes is warranted.  OBJECTIVES: To assess the effect of double-fortified salt (DFS) compared to iodised salt (IS) on measures of iron and iodine status in all age groups.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, five other databases, and two trial registries up to April 2021. We also searched relevant websites, reference lists, and contacted the authors of included studies.

SELECTION CRITERIA

All prospective randomised controlled trials (RCTs), including cluster-randomised controlled trials (cRCTs), and controlled before-after (CBA) studies, comparing DFS with IS on measures of iron and iodine status were eligible, irrespective of language or publication status. Study reports published as abstracts were also eligible.

DATA COLLECTION AND ANALYSIS

Three review authors applied the study selection criteria, extracted data, and assessed risk of bias. Two review authors rated the certainty of the evidence using GRADE. When necessary, we contacted study authors for additional information. We assessed RCTs, cRCTs and CBA studies using the Cochrane RoB 1 tool and Cochrane Effective Practice and Organisation of Care (EPOC) tool across the following domains: random sequence generation; allocation concealment; blinding of participants and personnel; blinding of outcome assessment; incomplete outcome data; selective reporting; and other potential sources of bias due to similar baseline characteristics, similar baseline outcome assessments, and declarations of conflicts of interest and funding sources. We also assessed cRCTs for recruitment bias, baseline imbalance, loss of clusters, incorrect analysis, and comparability with individually randomised studies. We assigned studies an overall risk of bias judgement (low risk, high risk, or unclear).  MAIN RESULTS: We included 18 studies (7 RCTs, 7 cRCTs, 4 CBA studies), involving over 8800 individuals from five countries. One study did not contribute to analyses. All studies used IS as the comparator and measured and reported outcomes at study endpoint.  With regards to risk of bias, five RCTs had unclear risk of bias, with some concerns in random sequence generation and allocation concealment, while we assessed two RCTs to have a high risk of bias overall, whereby high risk was noted in at least one or more domain(s). Of the seven cRCTs, we assessed six at high risk of bias overall, with one or more domain(s) judged as high risk and one cRCT had an unclear risk of bias with concerns around allocation and blinding. The four CBA studies had high or unclear risk of bias for most domains. The RCT evidence suggested that, compared to IS, DFS may slightly improve haemoglobin concentration (mean difference (MD) 0.43 g/dL, 95% confidence interval (CI) 0.23 to 0.63; 13 studies, 4564 participants; low-certainty evidence), but DFS may reduce urinary iodine concentration compared to IS (MD -96.86 μg/L, 95% CI -164.99 to -28.73; 7 studies, 1594 participants; low-certainty evidence), although both salts increased mean urinary iodine concentration above the cut-off deficiency. For CBA studies, we found DFS made no difference in haemoglobin concentration (MD 0.26 g/dL, 95% CI -0.10 to 0.63; 4 studies, 1397 participants) or urinary iodine concentration (MD -17.27 µg/L, 95% CI -49.27 to 14.73; 3 studies, 1127 participants). No studies measured blood pressure. For secondary outcomes reported in RCTs, DFS may result in little to no difference in ferritin concentration (MD -3.94 µg/L, 95% CI -20.65 to 12.77; 5 studies, 1419 participants; low-certainty evidence) or transferrin receptor concentration (MD -4.68 mg/L, 95% CI -11.67 to 2.31; 5 studies, 1256 participants; low-certainty evidence) compared to IS. However, DFS may reduce zinc protoporphyrin concentration (MD -27.26 µmol/mol, 95% CI -47.49 to -7.03; 3 studies, 921 participants; low-certainty evidence) and result in a slight increase in body iron stores (MD 1.77 mg/kg, 95% CI 0.79 to 2.74; 4 studies, 847 participants; low-certainty evidence). In terms of prevalence of anaemia, DFS may reduce the risk of anaemia by 21% (risk ratio (RR) 0.79, 95% CI 0.66 to 0.94; P = 0.007; 8 studies, 2593 participants; moderate-certainty evidence). Likewise, DFS may reduce the risk of iron deficiency anaemia by 65% (RR 0.35, 95% CI 0.24 to 0.52; 5 studies, 1209 participants; low-certainty evidence).  Four studies measured salt intake at endline, although only one study reported this for both groups. Two studies reported prevalence of goitre, while one CBA study measured and reported serum iron concentration. One study reported adverse effects. No studies measured hepcidin concentration.

AUTHORS' CONCLUSIONS

Our findings suggest DFS may have a small positive impact on haemoglobin concentration and the prevalence of anaemia compared to IS, particularly when considering efficacy studies. Future research should prioritise studies that incorporate robust study designs and outcome measures (e.g. anaemia, iron status measures) to better understand the effect of DFS provision to a free-living population (non-research population), where there could be an added cost to purchase double-fortified salt. Adequately measuring salt intake, both at baseline and endline, and adjusting for inflammation will be important to understanding the true effect on measures of iron status.

Gut microbiome-micronutrient interaction: The key to controlling the bioavailability of minerals and vitamins?

Micronutrients, namely, vitamins and minerals, are necessary for the proper functioning of the human body, and their deficiencies can have dramatic short- and long-term health consequences. Among the underlying causes, certainly a reduced dietary intake and/or poor absorption in the gastrointestinal tract play a key role in decreasing their bioavailability. Recent evidence from clinical and in vivo studies suggests an increasingly important contribution from the gut microbiome. Commensal microorganisms can in fact regulate the levels of micronutrients, both by intervening in the biosynthetic processes and by modulating their absorption. This short narrative review addresses the pivotal role of the gut microbiome in influencing the bioavailability of vitamins (such as A, B, C, D, E, and K) and minerals (calcium, iron, zinc, magnesium, and phosphorous), as well as the impact of these micronutrients on microbiome composition and functionality. Personalized microbiome-based intervention strategies could therefore constitute an innovative tool to counteract micronutrient deficiencies by modulating the gut microbiome toward an eubiotic configuration capable of satisfying the needs of our organism, while promoting general health.

Decisions to Start, Strengthen, and Sustain Food Fortification Programs: An Application of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Evidence to Decision (EtD) Framework in Nigeria

Background

Although the potential impact of food fortification to improve the micronutrient status of populations has been demonstrated beyond a doubt, it is constrained in practice by critical gaps in program design and implementation. These are partly linked to suboptimal decision making.

Objectives

We aimed to demonstrate how the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Evidence to Decision (EtD) framework for health system and public health decisions can be applied to formulate recommendations and make decisions in national food fortification programming.

Methods

Following a program impact pathway, we reviewed the literature to define the key decision types and identify the corresponding decision makers necessary for designing and implementing effective food fortification programs. We then applied the GRADE EtD framework to the Nigerian fortification program to illustrate how evidence-informed assessments and conclusions can be made.

Results

Fortification program decisions were classified into 5 types: 1) program initiation; 2) program design; 3) program delivery; 4) program impact; and 5) program continuation. Policymakers, food processors, and (in cases dependent on or considering external funding) development partners are the main decision makers in a fortification program, whereas technical partners play important roles in translating evidence into contextualized recommendations. The availability and certainty of evidence for fortification programs are often low (e.g., quality and coverage data are not routinely collected and there are challenges evaluating impact in such population-based programs using randomized controlled trials) yet decisions must still be made, underscoring the importance of using available evidence. Furthermore, when making program initiation and continuation decisions, coordination with overlapping micronutrient interventions is needed where they coexist.

Conclusions

This framework is a practical tool to strengthen decision-making processes in fortification programs. Using evidence in a systematic and transparent way for decision making can improve fortification program design, delivery, and ultimately health impacts.

Global Burden of Vitamin A Deficiency in 204 Countries and Territories from 1990-2019

Vitamin A deficiency (VAD) is one of the important public health issues worldwide. However, a detailed understanding of the incidence and disability-adjusted life years (DALYs) due to VAD in recent years is lacking. We aimed to estimate the incidence and DALYs of VAD at global, regional, and national levels in terms of sex, age, and socio-demographic index (SDI). Using data from the 2019 Global Burden of Disease (GBD) study, the estimated annual percentage change (EAPC) was measured to assess trends in the age-standardized incidence and DALY rates from 1990 to 2019. The global age-standardized incidence and DALY rates of VAD decreased with an EAPC of −3.11% (95% confidence interval (CI): −3.24% to −2.94%) and −2.18% (95% CI: −2.38% to −1.93%), respectively. The age-standardized incidence and DALY rates decreased least in low-SDI regions, which had the highest age-standardized incidence and DALY rates of all SDI regions. Sub-Saharan Africa, especially central sub-Saharan Africa, had the highest age-standardized incidence and DALY rates in 2019. At the national level, Somalia and Niger had the highest age-standardized incidence and DALY rates. The age-standardized incidence and DALY rates were higher in males than in females. Younger children, especially those aged < 5 years in low-SDI regions, had a higher VAD burden than other age groups. Although the global burden of VAD has decreased, future work should aim to improve the prevention and treatment strategies for VAD, particularly in children aged < 5 years in countries and territories with low SDI values, such as sub-Saharan Africa.

Iron Fortification through Universal Distribution of Double-Fortified Salt Can Increase Wages and Be Cost-Effective: An Ex-Ante Modeling Study in India

BACKGROUND

The alleviation of iron deficiency through iron supplementation has not effectively reduced anemia in India, mainly due to low compliance. Food fortification with iron is considered a viable alternative, and the provision of double-fortified salt (DFS; with iron and iodine) has been mandated in public health programs. Limited evidence exists on its benefit-cost ratio.

OBJECTIVE

In this study we sought to estimate the economic benefit in terms of increased wages in relation to introduction of DFS in reduction of anemia and the cost of doing so.

METHODS

The economic benefit of introducing DFS in India was derived using a series of mathematical, statistical, and econometric models using data from national surveys capturing earnings and dietary iron intake of the population. Anemia status was predicted from data on dietary intake, sanitation, and for women, menstrual losses. The impact of iron deficiency anemia (IDA) on wages was estimated using a Heckman Selection model and 2-stage least squares procedure. Benefit of DFS was estimated through increased wages attributed to anemia reduction compared with its cost.

RESULTS

Men and women with IDA had lower wages (by 25.9%, 95% CI: 11.3, 38.1; and by 3.9%, 95% CI: 0.0, 7.7, respectively) than those without IDA. Additional iron intake through DFS was predicted to reduce prevalence of IDA (from 10.6% to 0.7% in men and 23.8% to 20.9% in women). The economic benefit-cost ratio of introducing DFS at a national level was estimated to be 4.2:1.

CONCLUSIONS

Iron fortification delivered through DFS under a universal program can improve wages and be sufficiently cost-effective for its implementation at scale in India.