Impact of flour fortification with calcium on calcium intake: a simulation study in seven countries

Calcium intake is low in many countries, especially in low‐income countries. Our objective was to perform a simulation exercise on the impact, effectiveness, and safety of a flour fortification strategy using the Intake Modelling, Assessment, and Planning Program. Modeling of calcium fortification scenarios was performed with available dietary intake databases from Argentina, Bangladesh, Italy, the Lao People's Democratic Republic (Lao PDR), Uganda, Zambia, and the United States. This theoretical exercise showed that simulating a fortification with 156 mg of calcium per 100 g of flour would decrease the prevalence of low calcium intake, and less than 2% of the individuals would exceed the recommended calcium upper limit (UL) in Argentina, Italy, Uganda, and Zambia. Bangladesh and the Lao PDR showed little impact, as flour intake is uncommon. By contrast, in the United States, this strategy would lead to some population groups exceeding the UL. This exercise should be replicated and adapted to each country, taking into account the updated prevalence of calcium inadequacy, flour consumption, and technical compatibility between calcium and the flour‐type candidate for fortification. A fortification plan should consider the impact on all age groups to avoid the risk of exceeding the upper levels of calcium intake. This study shows that in some low‐ and middle‐income countries (LMICs), flour fortification would, in theory, increase calcium intake without posing the risk of excess of calcium intake in the population. However, in two LMICs, flour intake was so low that the impact on calcium intake was negligible, and fortification of other widely consumed foods should be considered. Results shown in this study are limited to the countries selected, but it can be hypothesized that similar results would be obtained in other LMICs. The analysis performed in this study is required in any country with the most updated information before implementing a fortification strategy.