ABSTRACT
Micronutrient fortification of staple foods can be an effective strategy to combat micronutrient malnutrition. When planning on fortification, challenges faced include the collection of essential information on population food and nutrient intake patterns, as well as the use of this information in a method to select appropriate fortification levels. A symposium was organized aimed at discussing the existing approaches to set effective and safe micronutrient fortification levels and to outline the challenges and needs in this area. Two different approaches to establish effective and safe fortification levels for food fortification were presented. In the first approach, the Estimated Average Requirement (EAR) and Tolerable Upper Intake Level (UL) are used as cut-points in the micronutrient intake distribution to evaluate and simulate effective and safe micronutrient intakes. This was exemplified by challenges encountered in Guatemala and Cameroon towards unequal vitamin A intake distribution and the impact of the food vehicle choice. Secondly, the risk-benefit approach was presented as an approach in which risks and benefits of micronutrient intakes can be quantified and balanced in order to optimize fortification benefits with the least risks and to allow decision making. This was illustrated by a case on folic acid fortification in The Netherlands. Irrespective of the approach, food and nutrient intake data are required to identify potential vehicles for fortification, quantify the nutrient gap to be addressed, and set the appropriate level of fortification based on consumption pattern. Such information is rarely available to the quality and extent ideal to set fortification levels and requires regular updating, as exemplified in the case of sugar fortification in Guatemala. While the EAR cut-point method can be used to determine the proportion of the population meeting their required and safe nutrient intakes and set goals, riskbenefit assessment may offer an answer to commonly-asked questions as to whether, and at which levels, the benefits of increasing micronutrient intakes outweigh the risks.
ABSTRACT
Objectives: Micronutrient deficiency can have serious health and economic implications. Food fortification with micronutrients is a main strategy countries can use to address population-wide deficiency. The objective was to compare different risk-benefit models that can be used to set micronutrient fortification levels. Methods: Different models to assess risks and benefits of food fortification were compared. Results: The EAR approach for setting micronutrient fortification levels uses point estimates at the lower and upper end of the intake range which should be both nutritionally adequate and safe. This approach considers the risk in terms of proportion of the population with intakes below the Estimated Average Requirement (EAR) and above the Tolerable Upper Intake Level (UL). However, the UL is based on the no- or lowest-observed adverse effect level (NOAEL or LOAEL) and includes an uncertainty factor and the adverse health consequences at intakes below the EAR may be very different from those above the UL both in terms of nature and severity. Risk-benefit methods exist that equally consider the health impact of micronutrient intake at the two ends of the intake spectrum. A common health metric (e.g. Disability-Adjusted Life Year) is used capturing severity, duration and incidence of the affected health condition(s) and death. Future integrated risk-benefit assessments of country-wide food fortification for example with vitamin A will illustrate the benefits and risks of fortification in terms of health impact. Conclusions: Estimating the health consequences of micronutrient fortification at both ends of the intake spectrum may assist in making deliberate decisions on food fortification programs.