In 2005, the Palestinian Authority decided to mandate the fortification of wheat flour with eight vitamins (Vitamins A and D, B-1, B-2, niacin, B-6, folic acid, and B-12), and 2 minerals (iron and zinc) as a strategy to reduce risk of micronutrient deficiencies due to reduction in the consumption of milk, eggs, and meat, poultry and fish. The same year, a study to determine micronutrient status and nutritional adequacy was carried out in Hebron and Gaza City to justify and adjust later the fortification formula. Dietary data was collected from 3-7 years old children and women of reproductive age (18-50 years old) of Hebron and Gaza City, as representatives of the poorest sections of the Palestinian society. Serum samples were also collected from the same age groups and deeply frozen until the determination of biomarkers associated to micronutrient status. Usual intakes and biomarkers were estimated in 2009.
The nutrient analysis revealed that for children and women of reproductive age in Hebron and Gaza City the largest nutritional inadequacies are for vitamin A, vitamin B-12, iron, zinc and calcium. Children older than 6 years of age and women might also be deficient for the vitamins B-1, B-2, B-6 and niacin, although biochemical confirmation is still pending. Women were more affected than children, especially for vitamin D and iron. Folate status was found good, although some women would still require additional intakes of folic acid to raise the serum folate levels to values that are being linked to prevention of neural tube defects. Based on the estimated intake data, it appears that supply of vitamin E and vitamin C are adequate for the Palestinian population, as well as vitamin D status in children.
Data suggest that higher levels of vitamin B-1, vitamin B-12 and zinc would be useful in the fortification formula of wheat flour. Adjustments in the contents of folic acid and vitamin D should be done based on future determinations of serum folate and serum vitamin D, respectively. The levels of the other micronutrients are appropriate for the current circumstances.
There is no sensitive biomarker for calcium deficiency but dietary data indicate that intakes of calcium are highly inadequate for the three groups studied, and probably for the entire population. Rising of calcium intakes would require the introduction of several strategies, such as promoting the production and consumption of milk and derivates, and supplementation and calcium fortification of food and beverages beyond wheat flour.
Consumption of fortified wheat flour would reduce prevalence of the micronutrient inadequacies on large segments of the Palestinian population. Nevertheless, it is estimated that additional sources of vitamin A would still be needed for children, as well as iron for women of reproductive age. Poor children of school age would also require some additional amounts of all micronutrients, but in much lower amounts than in the absence of fortified wheat flour. Use of supplements with several micronutrients instead of only iron and folic acid seems to be appropriate during pregnancy due to the large magnitude of deficiencies in women of reproductive age that was found in this study.
Formulation of foods both for school-feeding as well as for market-driven fortification should be regulated taken in consideration the micronutrient supply through fortified wheat flour; limitation in the use of vitamin A and folic acid seems to be necessary.
Determination of the nutritional status of children 1-3 years old deserves a special consideration, because it is a group at high risk, and because fortified wheat flour would benefit them less because the low consumption of products containing this food. Therefore, continuation of the programs of supplementation with vitamin A and D, and iron during infancy should continue. Use of powder supplements for home-fortification to improve the micronutrient density of the foods used to complement breast-feeding should also be considered.
The results of this study confirmed that the multiple fortification of wheat flour was a good decision as a public health measure in the Palestinian territories.
The combination of the dietary intake research and the nutritional status assessment analyses provided an excellent, and possibly the first, example of the complimentary value of having data on both nutrient intakes and biochemical markers of status. The dietary data are important for estimating the prevalence of inadequate intakes of specific nutrients, and for identifying potential fortification vehicles (e.g. wheat flour), the amount of micronutrients that are needed to be added to such foods in order to correct the intake gaps, and the calculation of the impact of different levels of fortification on the prevalence of inadequate or excessive intakes of each nutrient. The biochemical data were necessary to detect the high prevalence of vitamin D deficiency in women, and to confirm the prevalence of most deficiencies predicted from the food intake data. The biochemical values also provide a baseline for monitoring changes in the biochemical data after fortification. A final important point is that potential users of such information are usually more readily convinced by biomarker values than by nutrient intake data. Therefore it is advised that future monitoring and evaluation, and nutritional surveillance, initiatives should include both the use of dietary information, as well as key biomarkers of nutritional status. In addition to serum levels, the determination of the nutritional value of breast milk might be a useful way to assess the impact of wheat flour fortification as well as to estimate the nutritional status of breast-fed infants. Capability to carry out this type of work should be ensured as part of the policies in public health nutrition.