Background: Food fortification and biofortification are well-established strategies to address micronutrient deficiencies in vulnerable populations. However, the effectiveness of fortification programs is not only determined by the biological efficacy of the fortified foods but also by effective and sustainable implementation, which requires continual monitoring, quality assurance and control, and corrective measures to ensure high compliance. Objective: To provide an overview of efficacy, effectiveness, economics of food fortification and biofortification, and status of and challenges faced by large-scale food fortification programs in low- and middle-income countries (LMIC). Methods: A literature review of PubMed publications in English from 2000 to 2017, as well as gray literature, targeting nongovernmental organizations whose work focuses on this topic, complemented by national reports and a “snowball” process of citation searching. The article describes remaining technical challenges, barriers, and evidence gap and prioritizes recommendations and next steps to further accelerate progress and potential of impact. Results: The review identifies and highlights essential components of successful programs. It also points out issues that determine poor program performance, including lack of adequate monitoring and enforcement and poor compliance with standards by industry. Conclusions: In the last 17 years, large-scale food fortification initiatives have been reaching increasingly larger segments of populations in LMIC. Large-scale food fortification and biofortification should be part of other nutrition-specific and nutrition-sensitive efforts to prevent and control micronutrient deficiencies. There are remaining technical and food system challenges, especially in relation to improving coverage and quality of delivery and measuring progress of national programs.

In rural Mexico and in many developing countries micronutrient deficiencies, growth stunting, and morbidity from infectious diseases are highly prevalent in young children. We assessed the extent to which growth stunting could be reversed and the number of infectious disease episodes reduced by zinc and/or iron supplementation. In a double-blind, randomized community trial 219 Mexican preschoolers were supplemented with either 20 mg Zn as zinc methionine, 20 mg Fe as ferrous sulfate, 20 mg Zn + 20 mg Fe, or a placebo. After 12 mo, plasma zinc increased significantly in the two zinc-treated groups, and plasma ferritin was significantly higher in the two iron-treated groups. There was no effect of treatments on growth velocity or body composition. Children in both zinc-supplemented groups had fewer episodes of disease (zinc alone, 3.9 +/- 0.3; zinc+iron, 3.7 +/- 0.4; placebo, 4.6 +/- 0.5; P < 0.03), including diarrhea (zinc alone, 0.7 +/- 0.1; zinc+iron, 0.8 +/- 0.1; placebo, 1.1 +/- 0.2; P < 0.01). Zinc and zinc+iron supplements reduced morbidity but had no effect on growth or body composition.

Background: In developing countries, incomplete resolution of anemia with iron supplementation is often attributed to poor compliance or inadequate duration of supplementation, but it could result from deficiencies of other micronutrients. Objective: Our objective was to assess children's hematologic response to supervised, long-term iron supplementation and the relation of this response to other micronutrient deficiencies, anthropometry, morbidity, and usual dietary intake. Design: Rural Mexican children aged 18–36 mo (n = 219) were supplemented for 12 mo with either 20 mg Fe, 20 mg Zn, both iron and zinc, or placebo. Children were categorized as iron-unsupplemented (IUS; n = 109) or iron supplemented (IS; n = 108). Hemoglobin, hematocrit, mean corpuscular volume, mean cell hemoglobin, plasma concentrations of micronutrients that can affect hematopoiesis, anthropometry, and diet were assessed at 0, 6, and 12 mo; morbidity was assessed biweekly. Results: At baseline, 70% of children had low hemoglobin (≤115 g/L), 60% had low hematocrit, 48% were ferritin deficient, 10% had deficient and 33% had low plasma vitamin B-12 concentrations, 29% had deficient vitamin A concentrations, and 70% had deficient vitamin E concentrations. Iron supplementation increased ferritin from 11 ± 14 μg/L at baseline to 31 ± 18 μg/L after 6 mo (P < 0.001) and 41 ± 17 μg/L after 12 mo. However, anemia persisted in 30% and 31% of supplemented children at 6 and 12 mo, respectively, and was not significantly different between the IUS and IS groups at 12 mo. Initial plasma vitamin B-12, height-for-age, and dietary quality predicted the hematopoietic response to iron. Conclusion: Lack of hemoglobin response to iron was associated with indicators of chronic undernutrition and multiple micronutrient deficiencies.

Purpose To evaluate the total fluid intake from drinking water and beverages in adult populations from different countries and assess the percentage of individuals complying with the European Food Safety Agency (EFSA) adequate intake (AI) of water from fluids. Methods A total of 16,276 adults (7580 men and 8696 women) aged between 18 and 70 years (mean age 39.8 years) were randomly recruited from 13 different countries from three continents. Information about the total daily fluid intake (sum of drinking water and beverages) was collected using a 24-h fluid-specific record over seven consecutive days. Results Important differences in total fluid intake between countries were found; however, few differences between men and women were reported in most of the countries. Less than 50 % of the women and approximately 60 % of the men do not comply with the EFSA AI of water from fluids. Women were more than twice as likely as men to meet these AI (OR 2.15; 95 % CI 2.02–2.29). The odds of meeting the AI of water from fluids were lower in individuals over 50 years (OR 0.88; 95 % CI 0.80–0.96). Nine percent of the total population consumed less than half of the AI, 40.5 % between 50 and 100 %, and 50.5 % more than the AI. Conclusions There were considerable differences in total fluid intake between countries but not between genders. Only 40 % of men and 60 % of women comply with the EFSA AI of water from fluids. Men and elderly individuals had an increased risk of not complying with this reference value.