Impact of flour fortification with calcium on calcium intake: a simulation study in seven countries

Abstract

Calcium intake is low in many countries, especially in low-income countries. Our objective was to perform a simulation exercise on the impact, effectiveness, and safety of a flour fortification strategy using the Intake Modelling, Assessment, and Planning Program. Modeling of calcium fortification scenarios was performed with available dietary intake databases from Argentina, Bangladesh, Italy, the Lao People's Democratic Republic (Lao PDR), Uganda, Zambia, and the United States. This theoretical exercise showed that simulating a fortification with 156 mg of calcium per 100 g of flour would decrease the prevalence of low calcium intake, and less than 2% of the individuals would exceed the recommended calcium upper limit (UL) in Argentina, Italy, Uganda, and Zambia. Bangladesh and the Lao PDR showed little impact, as flour intake is uncommon. By contrast, in the United States, this strategy would lead to some population groups exceeding the UL. This exercise should be replicated and adapted to each country, taking into account the updated prevalence of calcium inadequacy, flour consumption, and technical compatibility between calcium and the flour-type candidate for fortification. A fortification plan should consider the impact on all age groups to avoid the risk of exceeding the upper levels of calcium intake.

Calcium concentration of drinking water to improve calcium intake: A simulation study

“…Strategies like calcium supplementation are usually not adequate for a whole population as they rely on adherence and access to supplements. Also, supplementation may not be adequate for small children 15,39 . Adding calcium to water in combination with other strategies, such as food fortification, should be evaluated specifically for each population 2,11,13 .…”

“…Also, supplementation may not be adequate for small children. 15,39 Adding calcium to water in combination with other strategies, such as food fortification, should be evaluated specifically for each population. 2,11,13 While planning an intervention to improve calcium intake in the population, vitamin D status should be considered.…”

Interventions to improve calcium intake through foods in populations with low intake

“…However, for calcium, the amount that would typically be added to a fortified food would be relatively low due to calcium's effect on organoleptic properties and acceptability when compared with the relatively high UL (2500 mg/day for most adults). Two recent analyses modeled the impact of calcium fortification of water and flour for several countries 35,111 . Flour fortification at the level of 156 mg per 100 g of flour would result in less than 2% of individuals (6 months and older) exceeding the UL in the six of the seven countries modeled from five continents 111 .…”

“…Two recent analyses modeled the impact of calcium fortification of water and flour for several countries. 35 , 111 Flour fortification at the level of 156 mg per 100 g of flour would result in less than 2% of individuals (6 months and older) exceeding the UL in the six of the seven countries modeled from five continents. 111 However, in two of these countries, the Lao PDR and Bangladesh, flour consumption is too low to have an impact on calcium intake.…”

“… 35 , 111 Flour fortification at the level of 156 mg per 100 g of flour would result in less than 2% of individuals (6 months and older) exceeding the UL in the six of the seven countries modeled from five continents. 111 However, in two of these countries, the Lao PDR and Bangladesh, flour consumption is too low to have an impact on calcium intake. In a similar modeling exercise of calcium‐fortified water (500 mg of calcium/L), which included five LMICs and two high‐income countries, the populations from the LMICs had the greatest potential to benefit from fortification, with very few individuals exceeding the UL.…”