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Consensus Recommendations for Prevention of Nutritional Rickets: Food Fortification and Micronutrient Supplements for Global Health

1 Department of Endocrinology & Diabetes, Birmingham Children’s Hospital; and Institute of Me-tabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
2 Department of Health Economics, Institute of Applied Health Research, University of Birming-ham, United Kingdom
3 Vitamin D Research Group, School of Food and Nutritional Sciences, University College Cork, Ireland
4 Professor Emeritus: Braun School of Public Health and Community Medicine, Hebrew University-Hadassah, 91220 Jerusalem, Israel. Head of School of Health Professions, Ashkelon College, Ashkelon, Israel

Special Issues: Health and Wealth, inequality and health status, public health nutrition: the major challenges to creating a healthier world

  Article Metrics

Keywords Food fortification; micronutrient deficiencies (MNDs); vitamin D; rickets; folic acid; iron; iodine; vitamin B complex; prevention

Citation: Wolfgang Högler, Magda Aguiar, Mairead Kiely, Theodore Tulchinsky. Consensus Recommendations for Prevention of Nutritional Rickets: Food Fortification and Micronutrient Supplements for Global Health. AIMS Public Health , 2016, 3(1): 40-48. doi: 10.3934/publichealth.2016.1.40


  • 1. International Food Policy Research Institute. 2015. Global Nutrition Report 2015: Actions and Accountability to Advance Nutrition and Sustainable Development. Washington, DC. Available at: http://www.ifpri.org/publication/global-nutrition-report-2015 (accessed 5 December 2015)
  • 2. United Nations. Millennium Development Goals Report 2015. United Nations, New York 2015. Available at: http://www.un.org/millenniumgoals/2015_MDG_Report/pdf/MDG%202015%20rev%20(July%201).pdf (accessed 11 November 2015).
  • 3. Black R (2003). Micronutrient deficiency - an underlying cause of morbidity and mortality. Bull World Health Organ. 81(1):79. Available at. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2572405/ (accessed 10 October 2015).
  • 4. Mandelbaum J (2004). Vitamin and mineral deficiencies harm one-third of the world's population. Bull World Health Organ. 82(3). Available at: http://www.who.int/bulletin/volumes/82/3/News.pdf (accessed 5 December 2015)
  • 5. Tulchinsky TH (2010). Micronutrient deficiency conditions: global health issues. Public Health Rev. 32:243-255. Available at: http://www.publichealthreviews.eu/show/f/28 9 (accessed 5 December 2015).
  • 6. Calvo MS, Whiting SJ, Barton CN (2005). Vitamin D intake: a global perspective of current status. J Nutr.135(2):310-316. Available at. http://www.ncbi.nlm.nih.gov/pubmed/1567123. (accessed 10 October 2015).
  • 7. Hossein-Nezhad A, Holick MF (2013). Vitamin D for health: a global perspective. Mayo Clin Proc. 88(7):720-55. Available at:.http://www.ncbi.nlm.nih.gov/pubmed/23790560    
  • 8. Munns C, Shaw N, Kiely M et al (2016). Global consensus recommendations on prevention and management of nutritional rickets. J Clin Endocrinol Metab. Jan 8:jc20152175. Available at: http://press.endocrine.org/doi/pdf/10.1210/jc.2015-2175
  • 9. Munns C, Shaw N, Kiely M et al (2016). Horm Res Paediatr. 85(2):83-106. Available at: http://www.karger.com/DOI/10.1159/000443136
  • 10. Swiglo BA, Murad MH.Schünemann HJ et al (2008). A case for clarity, consistency, and helpfulness: state-of-the-art clinical practice guidelines in endocrinology using the grading of recommendations, assessment, development, and evaluation system. J Clin Endocrinol Metab.93(3):666-73. Available at: http://www.ncbi.nlm.nih.gov/pubmed/18171699 (accessed 10 October 2015).
  • 11. Spiro A.Buttriss JL (2014). Vitamin D An overview of vitamin D status and intake in Europe. Nutr Bull.39(4):322-350.
  • 12. Braegger C, Campoy C, Colomb V et al ESPGHAN Committee on Nutrition (2013). Vitamin D in the healthy European paediatric population. J Pediatr Gastroenterol Nutr. 56(6):692-701.Available at: http://www.ncbi.nlm.nih.gov/pubmed/23708639 (accessed 5 December 2015)    
  • 13. Pettifor J (2014). Calcium and vitamin D metabolism in children in developing countries. Ann Nutr Metabl. 64(Suppl 2):15-22. Available at: http://www.ncbi.nlm.nih.gov/pubmed/2534187. (accessed 9 October 2015).
  • 14. Pettifor JM (2008). Vitamin D and/or calcium deficiency rickets in infants and children: a global perspective. Indian J Med Res. 127(3):245-249. Available at: http://www.ncbi.nlm.nih.gov/pubmed/18497438 (accessed 9 October 2015).
  • 15. Nowson CA, Margerison C (2002). Vitamin D intake and vitamin D status of Australians. Med J Aust. 177(3):149-52. Available at: http://www.ncbi.nlm.nih.gov/pubmed/12149085 (accessed 10 October 2015).
  • 16. Ozkan B (2010). Nutritional rickets. J Clin Res Pediatr Endocrinol. 2(4):137-142. Available at.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3005686. (accessed 9 October 2015).
  • 17. Whiting SJ, Langlois KA, Vatanparast H, Greene-Finestone LS (2011).The vitamin D status of Canadians relative to the 2011 Dietary Reference Intakes: an examination in children and adults with and without supplement use. Am J Clin Nutr. 94:128–35. Available at: http://ajcn.nutrition.org/content/94/1/128.full.pdf (accessed 7 November 2015).    
  • 18. Weisberg P, Scanlon KS, Li R, Cogswell ME (2004). Nutritional rickets among children in the United States: review of cases reported between 1986 and 2003. Am J Clin Nutr. 2004 Dec; 80(6):1697S-705S. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15585790 (accessed 5 December 2015)
  • 19. Thacher TD, Fischer PR, Tebben PJ et al (2013). Increasing incidence of nutritional rickets, a population-based study in Olmstead County, Minnesota. Mayo Clin Proc. 88(2):176-83. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3612965/pdf/nihms434117.pdf.(accessed 6 December 2015).    
  • 20. Högler W (2015).Complications of vitamin D deficiency from the foetus to the infant: One cause, one prevention, but who's responsibility? Best Pract Res Clin Endocrinol Metab. 29(3):385-98. Available at: http://www.ncbi.nlm.nih.gov/pubmed/26051298 (accessed 6 December 2015).    
  • 21. Kiely M, Black LJ (2012). Dietary strategies to maintain adequacy of circulating 25-hydroxyvitamin D concentrations. Scand J Clin Lab Invest Suppl. 2012;243:14-23. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22536758 (accessed 6 December 2015).
  • 22. Allen L, de Benoist B, Dary O, Hurrel R (eds) (2006). Guidelines on food fortification with micronutrients. World Health Organization/Food and Agriculture Organization, Geneva, 2006. Available at: http://www.unscn.org/layout/modules/resources/files/fortification_eng.pdf (accessed 24 October 2015)..
  • 23. Park YK, Sempos CT, Barton CN, et al (2000). Effectiveness of food fortification in the United States: the case of pellagra. Am J Public Health. 90(5):727-38. Available at: http://www.ncbi.nlm.nih.gov/pubmed/10800421 (accessed 10 October 2015).    
  • 24. United Kingdom Food Standards Agency (2008). The Bread and Flour Regulations 1998 (as amended). Available at: http://www.food.gov.uk/sites/default/files/multimedia/pdfs/breadflourguide.pdf (accessed 5 December 2015).
  • 25. Food Fortification Initiative (2015). Food control and monitoring. Website: http://www.ffinetwork.org/monitor (Accessed 25 October 2015).
  • 26. Food and Agriculture Organization (1995). Technical consultation on food fortification: technology and quality control: conclusions and recommendations..Available at: http://www.fao.org/docrep/w2840e/w2840e07.htm (Accessed 6 December 2015).
  • 27. Tulchinsky TH, Kaluski DN, Berry EM (2004). Food fortification and risk group supplementation are vital parts of a comprehensive nutrition policy for prevention of chronic diseases. Eur J Public Health. 14(3):226–228. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15369023 (accessed 6 December 2015)
  • 28. Tulchinsky T (2015). The key role of government in addressing the pandemic of micronutrient deficiency conditions in Southeast Asia. Nutrients. 7, 2518-2523. Available at: http://www.ncbi.nlm.nih.gov/pubmed/25856222 (accessed 6 December 2015)
  • 29. Centers for Disease Control and Prevention. Achievements in public health, 1900-1999 (1999). Safer and healthier foods. Morb Mort Wkly Rep MMWR. 48(40):905-913. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4840a1.htm (accessed 6 December 2015).
  • 30. Global Alliance for Improved Nutrition (2015). Fortifying our Future: a snapshot report on food fortification. Available at: http://www.gainhealth.org/wp-content/uploads/2015/05/Fortifying-our-Future-A-SnapShot-Report-on-Food-Fortification1.pd. (accessed 6 December 2015).
  • 31. Global Alliance for Improved Nutrition (2015). Nigeria food fortification, 2015. Available at: http://www.gainhealth.org/knowledge-centre/project/nigeria-large-scale-food-fortification/ (accessed 10 November 2015).
  • 32. Centers for Disease Control and Prevention (2008). Trends in wheat-flour fortification with folic acid and iron --- worldwide, 2004 and 2007. Morbid Mortal Wkly Rep MMWR. 57(01);8-10. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5701a4.htm 9 (accessed 5 December 2015).
  • 33. Sayed, AR, Bourne D, Pattinson R et al (2008). Decline in the prevalence of neural tube defects following folic acid fortification and its cost benefit in South Africa. Birth Defects Res A Clin Mol Teratol. 82 (April/4). p. 211-6.
  • 34. Blencowe H, Cousens S, Modell B, Lawn J (2010). Folic acid to reduce neonatal mortality from neural tube disorders. Int J Epidemiol. 39 (Suppl 1) p. i110–i121
  • 35. Public Health Agency of Canada (2012). Folic acid and prevention of neural tube defects: information update from PHAC -2008. Available at: http://www.phac-aspc.gc.ca/fa-af/fa-af08-eng.php (accessed 6 December 2015).
  • 36. Khoshnood B, Loane M, de Walle H et al. (2015). Long term trends in prevalence of neural tube defects in Europe: a population based study. BMJ. 351:h5949. Available at:. http://www.ncbi.nlm.nih.gov/pubmed/26601850 (accessed 5 December 2015).
  • 37. Lopez A, Cacoub P, Macdougall IC, Peyrin-Biroulet L (2015). Iron deficiency anaemia. Lancet. 2015 Aug 24. pii: S0140-6736(15)60865-0. doi: 10.1016/S0140-6736(15)60865-0. [Epub ahead of print]
  • 38. Domellöf M1, Braegger C, Campoy C, et al ESPGHAN Committee on Nutrition. (2014). Iron requirements of infants and toddlers. J Pediatr Gastroenterol Nutr. 58(1):119-29. Available at: http://www.ncbi.nlm.nih.gov/pubmed/24135983 (accessed 6 December 2015)    
  • 39. Pachón H, Spohrer R, Mei Z, Serdula MK. Evidence of the effectiveness of flour fortification programs on iron status and anemia: a systematic review. Nutr Rev. 2015 Nov;73(11):780-95. Available a.: http://www.ncbi.nlm.nih.gov/pubmed/26433017 (accessed 6 December 2015)
  • 40. Brittenham G (2004). Safety of Flour Fortification with Iron. Paper presented at 2004 Workshop for the Food Fortification Initiative. Available at: http://www.ffinetwork.org/why_fortify/documents/IronSafety2004.pdf (accessed 6 December 2015)
  • 41. Brittenham G (2012). Nestle Nutr Inst Workshop Ser. 70:117-27. Safety of iron fortification and supplementation in malaria-endemic areas. Available at: http://www.ncbi.nlm.nih.gov/pubmed/25762976 (accessed 6 December 2015)
  • 42. Centers for Disease Control and Prevention (2015). Hemochromatosis: risk factor and causes. Available at: http://www.cdc.gov/ncbddd/hemochromatosis/causes.html.(accessed 6 December 2015).
  • 43. Hurrell R, Ranum P, de Pee S et al (2010). Revised recommendations for iron fortification of wheat flour and an evaluation of the expected impact of current national wheat flour fortification programs. Food Nutr Bull. 31(1 Suppl):S7-21. Review.    
  • 44. Zimmermann MB, Biebinger R, Egli I et al (2011). Iron deficiency up-regulates iron absorption from ferrous sulphate but not ferric pyrophosphate and consequently food fortification with ferrous sulphate has relatively greater efficacy in iron-deficient individuals. Br J Nutr. 105(8):1245-50. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21205385 (accessed 6 December 2015)    
  • 45. Harvard School of Public Health Nutrition Source (2015). Vitamin D and health. Available at: http://www.hsph.harvard.edu/nutritionsource/vitamin-d/ (accessed 5 December 2015).
  • 46. Copenhagen Consensus Center. Copenhagen Consensus 2008–Results. Available at: http://www.copenhagenconsensus.com/sites/default/files/CC08_results_FINAL_0.pdf. (accessed 6 December 2015).
  • 47. United Nations. Sustainable Development Goals (2015). Goal 2: End hunger, achieve food security and improved nutrition and promote sustainable agriculture. Available at: http://www.un.org/sustainabledevelopment/hunger/ (accessed 10 November 2015).


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Copyright Info: 2016, Wolfgang Högler, et al., licensee AIMS Press. This is an open access article distributed under the terms of the Creative Commons Attribution Licese (http://creativecommons.org/licenses/by/4.0)

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