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aFormulation adequate for daily consumption of 50-200gday-1. If consumption is greater, micronutrient levels should be reduced.

Countries might reduce the levels of some micronutrients based on their particular nutritional profile and presence of other fortification programs with large public health coverage.

^Assuming US$0.40/kg.

cConsidering losses during food preparation.

dDietary folate = 1.7 x folic acid.

aFormulation adequate for daily consumption of 50-200gday-1. If consumption is greater, micronutrient levels should be reduced.

Countries might reduce the levels of some micronutrients based on their particular nutritional profile and presence of other fortification programs with large public health coverage.

^Assuming US$0.40/kg.

cConsidering losses during food preparation.

dDietary folate = 1.7 x folic acid.

Brazil, but national effectiveness studies are still pending. Oil is currently fortified with vitamin A in Coted'Ivoire, Mali, Morocco, Nigeria, Oman, Philippines, Uganda, and Yemen. These programs have been designed to provide at least 100 mg vitamin A (23% EAR), which may have some biological consequence in a portion of the population. The main restriction of this practice is the destruction of vitamin A when oil is exposed to light inside transparent bottles.

Sugar Fortified with Vitamin A

In the 1970s, the Central American countries suffered from vitamin A deficiency. The only food that was identified as a good vehicle for fortification (centrally produced, affordable fortification cost, and widely consumed) was sugar. The technology of the addition of vitamin A was developed and, together with the introduction of the intervention, its biological effectiveness was evaluated. Vitamin A level increased in serum and breast milk of individuals in poor communities. Sugar is now the most important source of this nutrient in El Salvador, Guatemala, Honduras, and Nicaragua. It supplies 200-1000 mg of vitamin A (50-200% EAR), depending on the daily consumption pattern (30-150 g day-1). Nowadays, vitamin A deficiency is practically nonexistent in those countries. Zambia started this program in 1998 but, differentiate from, Central America, the impact has been modest due to the lower sugar consumption (20 g day-1) and sugar use (50% of population compared with nearly 100% in Central America). Nevertheless, sugar is the main source of vitamin A for those who consume it in Zambia. Nigeria has already started to implement this program for all sugar refined in the country. The vitamin A added to sugar is micro-encapsulated, and hence the type of packaging has little influence on its stability.

Wheat Fortified with Multiple Micronutrients

The practice of adding micronutrients to restore the nutritional quality of wheat grain with iron, vitamins B1 and B2, niacin, and sometimes calcium has been followed by many wheat flour mills in developing countries since the 1950s, especially in those industries with links to companies in the US and Canada. Nevertheless, attention to fortification of wheat flour was raised in the 1990s as a measure advocated by international organizations to reduce iron deficiency. Generally, the iron source is elemental iron, either electrolytic or reduced iron; exceptions are Central America where ferrous fumarate is used, and Peru, Cuba, and Chile, which use ferrous sulfate. A study in Sri Lanka, where an additional 12mgday-1 of reduced (28% EAR) or electrolytic (56% EAR) iron was provided, did not find any improvement in hemoglobin levels after 2 years of treatment. Similarly, a study in Bangladesh, which supplied 3.3 mg day-1 of reduced iron (35% EAR) to 6-15-year-old children failed to modify any parameter associated with iron status. Only Chile has indirect evidence that iron from fortified wheat flour contributes to maintain good nutritional status of this nutrient. Wheat flour consumption in that country (250 g day-1) provides 7.5 mg day-1 iron from ferrous sulfate (69% EAR). Other studies are on-going with the purpose of assessing if it is legitimate to use electrolytic iron for the fortification of wheat flour.

Most recently, attention has been given to folic acid, after evidence that neural tube defects in the US and Canada were reduced by the intake of an additional 200 mgday"1 of folic acid (106% EAR), by means of the consumption of cereals fortified with this nutrient. These results have been confirmed in Chile, where bioavailability and biological utilization of folic acid was also clearly demonstrated.

Experimental efficacy trials of wheat flour fortified with vitamin A in the Philippines and Bangladesh have established that biological impact can be found with intake levels of 100-200 mgday"1 (25-50% EAR). Despite this finding, vitamin A has not been widely considered as a micronutrient to be added to wheat flour, although South Africa, Nigeria, and the Philippines have regulations including this micronu-trient as part of the formulation. In comparison with sugar, addition of vitamin A to wheat flour has a lower cost and slightly better stability.

In addition to iron and folic acid, many countries also include vitamins B1, B2, and niacin in the fortification formulations. This is the practice followed by most Latin American countries. Now, Latin America is also considering the incorporation of vitamin B12 and zinc. Biological effects of the presence of other nutrients apart from iron and vitamin A have not been systematically evaluated in developing countries. However, when wheat flour fortification started in the US, it was documented that cases of beriberi, ariboflavinosis, and pellagra, associated with vitamins B1, B2, and niacin deficiencies, respectively, decreased drastically.

Wheat flour fortification has now extended to Bahrain, Jordan, Morocco, Saudi Arabia, Pakistan, Iran, Indonesia, and some regions of China, Central Asian countries and a few African countries.

Corn Products Fortified with Multiple Micronutrients

In Venezuela, precooked and degermed corn flour is fortified with iron (reduced iron and ferrous fuma-rate, in a mixture 2:3), vitamins B1, B2, niacin, and vitamin A. The usual consumption of this food provides 2.4 mg of iron from ferrous fumarate (22% EAR), and 1.6 mg from reduced iron (3.7% EAR). It also supplies 200 mg of vitamin A (47% EAR). A formal evaluation of this program has not been carried out, although it has been associated with maintenance of the iron status of the population despite the economical deterioration of the country. This argument is controversial because the additional supply of iron is not high, and the prevalence of anemia was low only in the year when fortification was introduced, whereas anemia rates after fortification were similar to those existent before fortification. Without a study under controlled conditions it is difficult to assign the mentioned effect to this program. Fortified precooked corn flour is theoretically more important as a source of vitamin A than iron, but no experimental evidence has been obtained in this regard. Nevertheless, it is interesting to note that a national nutritional survey, carried out in 2002, did not find vitamin A deficiency in Venezuelan preschoolers.

In Africa, maize-meal is currently being used as a vehicle for iron, zinc, vitamin A, and B complex vitamins, including in some cases vitamin B12. Biological impact has not been evaluated.

Masa-corn flour is fortified with iron (reduced, or ferrous fumarate, or ferrous bisglycinate), and vitamins B1, B2, and niacin, in some Central American countries, and in Mexico also with zinc. Efficacy trials have shown the better bioavailability of NaFeEDTA over reduced iron in this matrix, although NaFeEDTA has not been used as yet in an industrial setting.

Salt Fortified with Iodine and Fluoride

Most developing countries have joined the initiative for universal salt iodization; evidence obtained worldwide confirms that this provides sufficient iodine to human populations. However, some countries have started to reduce the content of iodine, because of concerns of unnecessary or excessive supply. A few countries, such as Colombia, Costa Rica, Jamaica, Mexico and Uruguay, have also utilized salt as a vehicle for delivering fluoride with the purpose of reducing tooth decay. In Costa Rica, tooth decay was reduced 65% after 12 years of initiating the program. As in the case of iodine, fluoride content has recently been lowered after epidemiological monitoring determined that excessive fluoride was being supplied.

Soy/Fish Sauces and Curry Powder Fortified with Iron

Efficacy trials carried out with soy sauce in China and fish sauce in Vietnam that were fortified with NaFeEDTA have shown an impact on reduction of anemia and improvement in the iron status indicators. The amount of iron supplied was 10mgday_1, which is about 93% of the EAR assuming a diet with 10% iron bioavailability. The plan is now to make these experiences national programs. A similar study with curry powder in South Africa provided similar conclusions. In these cases, effectiveness and technical feasibility have been proven, and the existence of the program depends now on assuring industrial acceptance, permanent financing, and continuous enforcement.

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