{"id":26481,"date":"2024-01-24T08:49:57","date_gmt":"2024-01-24T08:49:57","guid":{"rendered":"https:\/\/www.kfindonesia.org\/?p=26481"},"modified":"2024-01-24T08:49:58","modified_gmt":"2024-01-24T08:49:58","slug":"global-coverage-of-mandatory-large-scale-food-fortification-programs-a-systematic-review-and-meta-analysis","status":"publish","type":"post","link":"https:\/\/www.kfindonesia.org\/en\/global-coverage-of-mandatory-large-scale-food-fortification-programs-a-systematic-review-and-meta-analysis\/","title":{"rendered":"Global Coverage of Mandatory Large-Scale Food Fortification Programs: A Systematic Review and Meta-Analysis"},"content":{"rendered":"

Abstract:<\/strong> Food forti\ufb01cation with micronutrients is widely implemented to reduce micronutrient de\ufb01ciencies and related outcomes. Although many factors affect the success of forti\ufb01cation programs, high population coverage is needed to have a public health impact. We aimed to provide recent global coverage estimates of salt, wheat \ufb02our, vegetable oil, maize \ufb02our, rice, and sugar among countries with mandatory forti\ufb01cation legislation. The indicators were the proportion of households consuming the: food, forti\ufb01able food (that is, industrially processed), forti\ufb01ed food (to any extent), and adequately forti\ufb01ed food (according to national or international standards). We estimated the number of in-dividuals reached with forti\ufb01ed 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 forti\ufb01ed salt (4.2 billion people), and 48.6% consumed adequately forti\ufb01ed salt in 64, 84, and 31 countries, respectively. Additionally, 77.4% of households consumed wheat \ufb02our, 61.6% consumed forti\ufb01able wheat \ufb02our, and 47.1% consumed forti\ufb01ed wheat \ufb02our (66.2 million people) in 15, 8, and 10 countries, respectively, and 87.0% consumed vegetable oil, 86.7% consumed forti\ufb01able oil, and 40.1% consumed forti\ufb01ed oil (123.9 million people) in 10, 7, and 5 countries, respectively. Data on adequately forti\ufb01ed wheat \ufb02our and vegetable oil and coverage indicators for maize \ufb02our, rice, and sugar were limited. There are major data gaps on forti\ufb01cation coverage for most foods except salt. All countries with mandatory forti\ufb01cation programs should generate and use more coverage data to assess program performance and adjust programs as needed to realize their potential to reduce micronutrient de\ufb01ciencies (PROSPERO CRD42021269364).
Keywords: forti\ufb01cation, coverage, salt, maize, wheat \ufb02our, sugar, rice, vegetable oil<\/p>\n\n\n\n

F. Rohner et al.
Introduction
<\/strong>Globally, 1 in 2 preschool-aged children and 2 in 3 women of reproductive age are affected by \udbc0\udc011 micronutrient de\ufb01ciency [1]. Micronutrient de\ufb01ciencies can have considerable negative consequences on an individual\u2019s survival and mental and phys-ical development, which in turn negatively affects the economies of countries as a whole [2,3]. Micronutrient de\ufb01ciencies can be caused by low micronutrient intake due to a lack of dietary di-versity, suboptimal absorption, and\/or increased micronutrient losses due to infections [4].

Food forti\ufb01cation, or the addition of micronutrients lacking in a population\u2019s diet to commonly consumed foods at the point of processing, is a widely used and sustainable approach to increasing micronutrient intakes at a large scale [5]. It has been shown to reduce micronutrient de\ufb01ciencies and improve func-tional outcomes, such as reduced odds of developing anemia, goiter, or neural tube defects [6]. Food forti\ufb01cation \ufb01rst began in the early 1900s with the parboiling of rice in the Philippines [7]. This was followed in the 1920s with the addition of iodine to salt in Switzerland and the United States [8]. Subsequently, other micronutrients were added to cereals and milk in the United States and Canada [9,10]. It then expanded to sugar in Latin America in the 1970s, salt globally in the 1990s [11], and other staple foods and condiments in Africa and Asia in the 2000s [12].

Although many factors affect the success of food forti\ufb01cation programs [13], high population coverage is needed to have a public health impact. To understand the extent to which forti\ufb01ed foods are reaching a meaningful proportion of the population and in amounts that are suf\ufb01cient to shift the distribution of micronutrient intakes toward adequacy, it is ideal to track changes in population-level coverage and consumption patterns of forti\ufb01ed foods at regular intervals throughout the imple-mentation of a forti\ufb01cation program [13]. Such assessments should collect information on key indicators that provide evi-dence of delivery effectiveness and identify potential program-matic bottlenecks. Different measures of coverage speci\ufb01cto food forti\ufb01cation programs that serve this purpose have been previously de\ufb01ned and collected in several countries [14,15].

Despite the advantages of tracking coverage, this information is not routinely collected for most forti\ufb01ed foods [16]. Globally, Demographic Health Surveys (DHS) and UNICEF\u2019s Multiple In-dicator Cluster Surveys (MICS) regularly collect information on the household coverage of forti\ufb01ed salt but not of other commonly-forti\ufb01ed staple foods [17,18]. Other surveys that assess coverage of multiple forti\ufb01ed foods at national- or sub-national levels, such as Forti\ufb01cation Assessment Coverage Toolkit (FACT) surveys [19], have been conducted sporadically in several countries [14,15]. Although some efforts have been made to consolidate the \ufb01ndings from FACT surveys across countries to understand common programmatic bottlenecks [16], a comprehensive assessment of all available coverage data has not yet been conducted to our knowledge.

In this systematic review we provide coverage and population reach estimates of 6 widely forti\ufb01ed foods (that is, salt, wheat \ufb02our, vegetable oil, maize \ufb02our, rice, and sugar) in countries with mandatory food forti\ufb01cation legislation. To assess the per-formance of food forti\ufb01cation programs in different contexts, we aimed to estimate coverage and reach for the aforementioned foods by geographic region, country-level income classi\ufb01cation, residence (that is, urban\/rural), and subnational socioeconomic status. Finally, we aimed to identify country-level factors that enable and limit the coverage of forti\ufb01ed foods.<\/p>\n\n\n\n