{"id":26461,"date":"2024-01-24T08:35:39","date_gmt":"2024-01-24T08:35:39","guid":{"rendered":"https:\/\/www.kfindonesia.org\/?p=26461"},"modified":"2024-01-24T08:35:40","modified_gmt":"2024-01-24T08:35:40","slug":"exploring-the-complementarity-of-fortification-and-dietary-diversification-to-combat-micronutrient-deficiencies-a-scoping-review","status":"publish","type":"post","link":"https:\/\/www.kfindonesia.org\/en\/exploring-the-complementarity-of-fortification-and-dietary-diversification-to-combat-micronutrient-deficiencies-a-scoping-review\/","title":{"rendered":"Exploring the Complementarity of Fortification and Dietary Diversification to Combat Micronutrient Deficiencies: A Scoping Review"},"content":{"rendered":"
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2023<\/p>\n<\/blockquote>\n\n\n\n

Abstract<\/h3>\n\n\n\n

Achieving a balanced and diverse diet remains a challenge for many people, contributing to an ongoing burden of micronutrient de-\ufb01ciencies, particularly in low-income settings. Forti\ufb01cation or dietary diversi\ufb01cation are common food-based approaches. We conducted a scoping review to: 1) \ufb01nd evidence on whether combined food\u2013based strategies are more effective than single strategies, and 2) understand how strategies implemented together could complement each other to achieve optimal nutritional impact on populations. Peer-reviewed articles selected (n \u00bc 21) included interventions or observational studies (n \u00bc 13) and reviews (n \u00bc 8). We found little evidence of an added nutritional impact. On the other hand, it is apparent that forti\ufb01cation and dietary diversi\ufb01cation target different types of settings (urban compared with rural) and foods (that is, low priced compared with highly priced). Further research is needed to understand the complementarity of these approaches and establish evidence of the effectiveness of combined strategies to foster policy adoption.
Keywords: food diversity, forti\ufb01cation, bioforti\ufb01cation, hidden hunger, nutritional impact, integrated food-based strategies<\/p>\n\n\n\n

Introduction<\/h3>\n\n\n\n

Micronutrient de\ufb01ciencies continue to pose a major global public health problem, particularly in low- and middle-income countries (LMICs), contributing to impaired linear growth of children, reduced immunocompetence, and suboptimal cogni-tive development, thereby impeding the development of both individuals and societies. A recent study estimates that 1 in 2 preschool aged children, and 2 in 3 women of reproductive age are de\ufb01cient in \udbc0\udc011 vitamins or minerals [1]. Despite data gaps, global estimates based on the analysis of existing national sur-veys reveal that vitamin A de\ufb01ciency in children has improved in East Asia but remains high in South Asia and Africa [2]. The extent of zinc de\ufb01ciency remains uncertain due to limited data, but it is estimated to affect >20% of children living in LMICs [3]. Universal iodization of salt has signi\ufb01cantly reduced iodine de\ufb01ciency, but there are 25 countries in which mild to moderate forms of iodine de\ufb01ciency remain prevalent [4]. In addition, folate de\ufb01ciency is still a major issue, linked to an estimated 260,100 neural tube defects (including ~175,000 stillbirths and neonatal deaths) [5]. Anemia continues to affect an estimated 41.6% of children and 32.6% of women of repro-ductive age globally, with data suggesting iron de\ufb01ciency to be an important, but not the only cause [6,7].

Efforts to combat the burden of these de\ufb01ciencies over many decades have included a range of nutrition-speci\ufb01c and nutrition-sensitive interventions [8] which can be broadly grouped into four categories: micronutrient supplementation; forti\ufb01cation A. Bechoff et al.
(including bioforti\ufb01cation); dietary diversi\ufb01cation; and public health and disease control (Figure 1). Forti\ufb01cation and dietary diversi\ufb01cation fall under food-based strategies whereas the other two strategies are part of a health approach. These strategies were \ufb01rst described at the International Conference on Nutrition, organized by the FAO and WHO in December 1992 [9]. Bio-forti\ufb01cation\u2014referred to as micronutrient-enhanced crops by the European Commission\u2014was not developed at this time, but was included in later guidelines [10]. Food-based approaches to improve micronutrient status focus on the consumption of foods that are either naturally rich in micronutrients or have been enriched through forti\ufb01cation [11].

We distinguish different forms of forti\ufb01cation depending on the process and the stage at which micronutrients are added. With industrial forti\ufb01cation, home forti\ufb01cation or food-to-food forti\ufb01cation, micronutrients are added at the site of processing or point of use (consumption), whereas in bioforti\ufb01cation, micronutrient content is increased during cultivation, generally using conventional breeding techniques or micronutrient-enhanced fertilizers. Dietary diversi\ufb01cation involves increasing the range of foods consumed to better meet the requirements for macro- and micronutrient intake. Although food forti\ufb01cation focuses on increasing the content of one or more speci\ufb01c nutri-ents in staple foods, dietary diversi\ufb01cation typically relates to the introduction or more frequent consumption of nonstaple foods in existing diets.

Industrial forti\ufb01cation and bioforti\ufb01cation have gained most attention in nutritional policies, but concerns have been raised about whether promoting forti\ufb01cation as a standalone approach could divert policy makers from other strategies such as supporting diverse and healthy diets [12,13]. Forti\ufb01cation strategies could lead to a limited impact on micronutrient de\ufb01ciencies, because food forti\ufb01cation is often with a limited number of micronutrients (for example, iodized salt or vitamin A forti\ufb01ed oils), and there are constraints to the amount of micronutrients in bioforti\ufb01ed foods that can be achieved through breeding. Likewise, there are chal-lenges linked to the implementation of dietary diversi\ufb01cation as a single strategy, as foods naturally rich in micronutrients are often unaffordable for the poorer segments of societies, and linear pro-gramming analyses suggest that local foods may be unable to meet nutrient requirements for some population groups in some settings [14\u201316]. Moreover, producers in rural settings often face various constraints to produce diversi\ufb01ed commodities, and the effects of production diversity on smallholder farming households\u2019 diets varies between settings [17,18].

To accelerate progress in improving micronutrient status of populations globally, policy recommendations have called for integrating food-based approaches [6,9]. Despite a body of evi-dence to support the impact on nutritional status of food-based strategies taken separately, there is a knowledge gap about the effectiveness of those actions used in combination [19]. We hy-pothesize that combining food forti\ufb01cation with diversi\ufb01cation of diets would lead to improved nutritional outcomes compared with strategies focusing on either approach alone. The objective of this article is to evaluate the combination, and potential complementarity, of forti\ufb01cation and dietary diversi\ufb01cation to improve the micronutrient status of populations.<\/p>\n\n\n\n