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The Association of Schools of Public Health in the European Region (ASPHER)

ASPHER is the key independent European organisation dedicated to strengthening the role of public health by improving education and training of public health professionals for both practice and research.



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Proceedings of Conference of 7 November 2019 Report  

See the full Conference Proceedings Report available for download here.

In the first decades of the 20th century epidemics of dietary deficiency conditions occurred with pellagra, goiter, and rickets in the United States. Pellagra killed 100,000 people in southern states. Medical opinion was that pellagra was due to an unknown infection, but investigation showed it to be a disease due to deficiency the vitamin niacin (vitamin B3). Goiter was widespread in Europe and in US states near the Great Lakes due to iodine deficiency leading to salt fortification in Switzerland, and the US from the 1920s. Rickets was highly prevalent in children in large urban slums in New York, in England and elsewhere, shown to be due to vitamin D deficiency.

In the US public concern for prevention of vitamin and mineral deficiencies resulted in support for food fortification; iodine added to salt, with vitamins B and iron to flour and vitamin D to milk increasing from the 1930s. Many countries among the Western Allies in World War II adopted mandatory fortification to protect civilian health during wartime, but this was relaxed in the post war era. After recurrence of deficiencies were reported clinically, and affirmation by a national nutritional survey in the early 1970s, Canada led the way with 1979 with implementation of mandatory fortification of salt, milk and flour.

Israel maintained fortification of margarine and low fat milk with vitamin D. Flour fortification was maintained until the 1970s but abandoned for no discernable reason. Concern for micronutrient deficiencies grew in the 1990s following many publications by clinicians indicated deficiencies in various population groups. The Ministry appointed an expert committee in the 1996 which recommended a mandatory food fortification policy on “the Canadian model”. But opposition mainly from the food manufacturing sector was a hindrance to implementation. Two more expert committees in the new century again recommended the same Canadian mandatory policy, supported by WHO guidelines, and other international recommendations. The issue of fortification came to public debate especially following the identification of folic acid flour enrichment reduced neural tube birth defects. In 2006, the neighbouring Palestinian Authority and Jordan implemented mandatory fortification of flour, salt and milk, which was successfully implemented.

Ashkelon Academic College in joint sponsorship with the Israel Ministry of Health and the Israeli Association of Public Health Physicians held a conference on the topic of micronutrient deficiency conditions in the county and food fortification. The conference was addressed by an international expert in this field, Prof Omar Dary who was a key consultant in adoption of fortification in the Palestinian Authority. The Conference was presented with data indicating from various studies and national surveys indicating widespread deficiencies in essential micronutrients in the population in all age and ethnic sectors of the population. The Conference supported the Ministry policy of mandatory food fortification including salt with iodine, milk with vitamin D, and flour with iron, vitamin B complex, folic acid and vitamin B12, supported by ongoing monitoring of micronutrient status of the population.

Evidence of micronutrient deficiencies appear to be widespread in the European Region as well. The Proceedings of this conference are relevant to many countries in Europe and globally. As a longstanding supporter of ASPHER, I recommend similar conferences to bring together data and policy implications in other countries which have similar challenges to address. Thus I have asked ASPHER to post these Proceedings on ASPHER’s website.

Ted Tulchinsky MD MPH

Ashkelon College,

Ashkelon, Israel

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