Exploration of strategic food vehicles for vitamin D fortification in low/lower-middle income countries

We previously identified 7 low/lower-middle income countries (LMICs; Afghanistan, Pakistan, India, Mongolia, Yemen, Nigeria, Tunisia) which have excess burden of vitamin D deficiency and could benefit enormously from food fortification with vitamin D. A key challenge is finding a suitable industrially-manufactured food vehicle that is consumed in sufficient amounts by the population at-risk. We used FAO Food Balance Sheet data (from 2003-2013) to model the potential impact of four different food vehicles (edible plant-based oil, wheat flour, maize flour, and milk), and at different addition levels, on the average per capita vitamin D supply in all 7 LMICs. Daily per capita supply for "95 foods was calculated and vitamin D supply determined using dietary analysis software with no addition and following stepwise additions of vitamin D to the four food vehicles. The daily per capita vitamin D supply without fortification ranged from 0.4 to 3.3 mu g (<= 2 mu g/d in six LMICs). We applied a vitamin D intake of 5 mu g/d as a benchmark because it maintains serum 25-hydroxyvitamin D >= 25 nmol/L in 90% of individuals. Modelling showed that fortifying edible oil with vitamin D at the 7.5 mu g/100 g (guideline) and 15 mu g/100 g levels allowed vitamin D supply in 1 and 3 of the 7 LMICs, respectively, to attain >= 5 mu g/d (range: 5.8-11.0 mu g/d). Fortifying milk at the 1.0 mu g/100 g and 2.0 mu g/100 g guideline levels, allowed 2 and 3 LMICs, respectively, to attain >= 5 mu g/d (range: 5.2-9.8 mu g/d). Fortifying wheat flour at the 1.4 mu g/100 g (guideline) and 2.8 mu g/100 g allowed 5 and 6 LMICs, respectively, to attain 5 mu g/d (range: 5.3-18.6 mu g/d). Maize flour had low impact due to consumption levels. In conclusion, using these levels of addition, at least one food vehicle was able to increase per capita vitamin D supply to >= 5 mu g/d in each of the LMICs.