Fortification

Fortification of staple foods serves as a cost effective means to increase iron intake in a population. Important factors that influence the success of a fortification program include availability of fortification technology, proper quality control at factories and/or mills, choosing a staple food that is widely and regularly consumed by all socioeconomic and geographical groups (including the most vulnerable groups), determining the most appropriate fortificant and the level of fortification necessary, assessing the bioavailability of the fortificant in food, and monitoring and evaluation [54]. Several countries including Venezuela, Chile, and the United States have successfully implemented food fortification programs. However, monitoring and evaluation of the effect of iron fortification programs on anemia prevalence is scarce. An analysis of anemia in school-age children suggested that fortification of wheat and corn flour in Venezuela in 1993 reduced anemia; however, this program's effectiveness needs further evaluation [55]. Several efficacy trials of staple food fortification have shown a reduction in iron deficiency and/or anemia, such as fortification of fish sauce in Vietnam, curry powder in India, soy sauce in China, and salt in Morocco [55-58]. Chile's compulsory fortification program, in which wheat flour is fortified with ferrous sulfate, folic acid, and other B vitamins, has successfully reduced the incidence of neural tube defects and folate deficiency in the population and has likely reduced the incidence of IDA, which is very low compared with other South American countries [59, 60]. A recent analysis of the consumption of fortified wheat flour in Guatemala illustrated that households bought an average of 84 g/day of fortified wheat flour equivalents (wheat flour plus breads made with fortified wheat flour) per adult equivalent unit, and this varied by socioeconomic status, ethnicity, and area [61]. Extremely poor, poor, and nonpoor households purchased 14, 48, and 124 g/day of wheat flour equivalents, respectively. Overall, purchases were lowest in extremely poor, indigenous, and rural households. This analysis illustrates that fortification of a staple food such as wheat flour can potentially benefit a population in which iron intake is low; however, the staple food must be consumed by all segments of the population in order to benefit the most vulnerable groups, such as the extremely poor. Fortification of staple foods, if implemented and monitored correctly, provides a cost-effective additional source of dietary iron for entire populations.

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