ESPE Yearbook of Paediatric Endocrinology

Am J Clin Nutr. 2019 Jun 1;109(6):1696–1708. DOI: 10.1093/ajcn/nqz023

• This systematic review and meta-analysis aimed to determine the impact of large-scale food fortification (LSFF) on health and nutrition outcomes in low- and middle-income countries (LMIC).

• The authors demonstrate that LSFF increases serum micronutrient concentrations including iodine, with a positive impact on functional outcomes such as a 74% reduction in the odds of goiter.

Micronutrient malnutrition is prevalent in LMIC and associated with the global burden of poverty and disease. Iodine deficiency disorders are the most common cause for preventable neurodevelopmental delay. While salt iodization has long been established as an effective strategy to eliminate iodine deficiency and its disorders, according to the most recent 2017 Iodine Global Network score card, 20 countries in the world remain iodine deficient (1).

This systematic review provides real-world evidence that LSFF increases micronutrient concentrations and reduces adverse health outcomes. The significant reductions in iodine deficiency disorders by means of universal salt iodization are highlighted as a success. While this is indeed encouraging, our challenge remains to eliminate iodine deficiency on a global scale. As much as salt iodization and other LSFF seem like straight forward interventions, as per the WHO/CDC logic model for micronutrient interventions (2), they do require financial and infrastructure resources to be established; policy frameworks, adequate production and supply, quality control, delivery mechanisms, communication and behavior change strategies to run successfully; and adequate program access and coverage to reach the target population. All of these processes are subject to vulnerability, with issues such as poor vehicle choice, challenges with large-scale distribution, and non-adherence to fortification recommendations being common. Recent experience with iodine status re-evaluation in Haiti (unpublished data) and Tanzania, two countries that are still iodine-deficient, highlight that challenges remain in almost every aspect of LSFF such as salt iodization. Thus, while additional research is needed to inform LSFF program priorities and tackle coverage and access issues among the poor and most vulnerable, the study’s findings should encourage widespread use of LSFF, an intervention already largely contributing to alleviating micronutrient malnutrition.

References: 1. Iodine Global Network. Global Scorecard of Iodine Nutrition in 2017 in the general population and in pregnant women (PW). IGN: Zurich, Switzerland. 2017. www.ign.org/cm_data/IGN_Global_Scorecard_AllPop_and_PW_May2017.pdf (Accessed June 30, 2019).

2. WHO/CDC. Logic model for micronutrient interventions in public health. [Internet]. Geneva (Switzerland): WHO; 2016. Available from: http://apps.who.int/iris/bitstream/10665/250746/3/WHO-NMH-NHD-EPG-16.1-colour-eng.pdf (Accessed June 30, 2019).