Projected effectiveness of mandatory industrial fortification of wheat flour, milk, and edible oil with multiple micronutrients among Mongolian adults

Abstract

Industrial fortification of wheat flour is a potentially effective strategy for addressing micronutrient deficiencies in Mongolia, given its ubiquitous consumption and centralized production. However, Mongolia has not mandated fortification of any foods except for salt with iodine. This study modeled the effectiveness and safety of mandatory industrial fortification of wheat flour alone and in combination with edible oil and milk in reducing the prevalence of multiple micronutrient intake deficiencies among healthy non-pregnant adults in Mongolia. Six days of diet records (3 summer, 3 winter) were collected from 320 urban and rural adults across the country and analyzed for food and nutrient consumption using a purpose-built food composition table, and the Intake Monitoring and Planning Program (IMAPP) was used to project the effects of fortification on summer and winter bioavailable micronutrient intake and intake deficiency under different fortification guidelines within population subgroups defined by urban or rural locality and sex. Projections showed that flour fortification would be effective in reducing intake deficiencies of thiamin and folate, while marginal benefits of fortification with iron and riboflavin would be smaller given these nutrients’ higher baseline consumption, and fortification with zinc, niacin, and vitamin B12 may be unnecessary. Fortification of flour, oil, and milk with vitamins A, D, and E at levels suggested by international guidelines would substantially reduce vitamin A intake deficiency and would increase vitamin D intake considerably, with the greatest benefits elicited by flour fortification and smaller benefits by additionally fortifying oil and milk. These results support mandatory industrial fortification of wheat flour, edible oil, and milk with iron, thiamin, riboflavin, folate, and vitamins A, D, and E in Mongolia. Considerations will be necessary to ensure the fortification of these nutrients is also effective for children, for whom the potential benefit of zinc, niacin, and vitamin B12 fortification should be assessed.

Diet and Nutrition Status of Mongolian Adults

“…Fourth, despite the size and breadth of the study population (comprising 1838 person-days of summer and winter prospective dietary intake from urban and rural men and women in 8 national provinces), and the use of random sampling within each province, the study population is not intended to be nationally-representative and results should be interpreted in the context of the sampling frame. Readers of our earlier fortification modeling study [16], which includes national estimates for the baseline prevalence of dietary inadequacy of ten nutrients using data from the same population as the present study, will note moderate quantitative differences between those and the present results for thiamin and vitamin A in some subgroups. These differences may be attributable to differing methodologies used in estimating intake distributions as well as our earlier use of survey weights.…”

“…Inadequate intake of calcium, vitamin D, and magnesium may jointly contribute to the relatively high prevalence of osteoporosis in Mongolian adults [35], and low intake of fiber has been linked to higher risk of heart disease, type 2 diabetes, and metabolic syndrome in large prospective cohort studies [36][37][38]. Implications of observed deficits of folate and other nutrients are discussed in previous studies by our group [16], in which we have also suggested evidence-based interventions to reduce the prevalence of micronutrient deficiency in the Mongolian population, including industrial food fortification and micronutrient supplementation [9,16,39]. As micronutrients work together to allow healthy body functioning and prevent disease, addressing multiple inadequacies (particularly through large-scale diet modification in the long term) may reap multiplicative benefits, and ensuring adequate micronutrient intake should remain integral to Mongolia's national health policy.…”

“…The objective of this study was to provide a multifaceted nutritional analysis of the modern Mongolian diet, using paired summer and winter weighed diet records collected from urban and rural Mongolian men and women living in 8 regions of the country. As part of a prior analysis based on these diet records [16], we reported the extent of population dietary inadequacy of 10 micronutrients; the present analysis extends this investigation to 21 nutrients, includes analysis of daily intake of food groups and their contributions to nutrient intakes, and includes exploratory analysis of population diet patterns. To support interpretation of the dietary data, we also assessed anthropometry and selected micronutrient biomarkers.…”

Awareness and Attitudes Regarding Industrial Food Fortification in Mongolia and Harbin

“…Biochemical analyses of Chinese children have found a high prevalence of calcium, iron, zinc, and selenium deficiency; high prevalence of mild iodine deficiency, marginal vitamin A deficiency, and vitamin D insufficiency; and moderate prevalence of thiamine, riboflavin, and vitamin B12 deficiency nationwide [4]. In a Mongolian nationwide survey from 2012 to 2016, dietary inadequacies of thiamin, folate, and vitamins A, D, and E were common among Mongolian adults [5], while a 2006 study of young children aged 6–24 months noted dietary inadequacies of calcium, iron, zinc, and vitamins A and C to be of concern [6]. Biochemical deficiencies of iron, zinc, folic acid, and vitamins A and D have been reported among Mongolian women of reproductive age and young children [2,7,8].…”

“…Mongolia’s small population and centralized production of staple foods should facilitate expanded fortification legislation there [5]. Eleven years after the conclusion of an Asian Development Bank-funded infrastructural project and effectiveness trial [7,19], renewed public sector advocacy efforts led the Mongolian parliament to pass a law in April 2018 expanding mandatory industrial fortification beyond that of salt; national program implementation is planned in January 2020 [20].…”