The global neurosurgery movement arose at the crossroads of unmet neurosurgical needs and public health to address the global burden of neurosurgical disease. The case of folic acid fortification (FAF) of staple foods for the prevention of spina bifida and anencephaly (SBA) represents an example of a new neurosurgical paradigm focused on public health intervention in addition to the treatment of individual cases. The Global Alliance for the Prevention of Spina Bifida-F (GAPSBiF), a multidisciplinary coalition of neurosurgeons, pediatricians, geneticists, epidemiologists, food scientists, and fortification policy experts, was formed to advocate for FAF of staple foods worldwide. This paper serves as a review of the work of GAPSBiF thus far in advocating for universal FAF of commonly consumed staple foods to equitably prevent SBA caused by folic acid insufficiency.
A narrative review was performed using the PubMed and Google Scholar databases.
In this review, the authors describe the impact of SBA on patients, caregivers, and health systems, as well as characterize the multifaceted requirements for proper spina bifida care, including multidisciplinary clinics and the transition of care, while highlighting the role of neurosurgeons. Then they discuss prevention policy approaches, including supplementation, fortification, and hybrid efforts with folic acid. Next, they use the example of FAF of staple foods as a model for neurosurgeons\' involvement in global public health through clinical practice, research, education and training, and advocacy. Last, they describe mechanisms for involvement in the above initiatives as a potential academic tenure track, including institutional partnerships, organized neurosurgery, neurosurgical expert groups, nongovernmental organizations, national or international governments, and multidisciplinary coalitions.
The role of neurosurgeons in caring for children with spina bifida extends beyond treating patients in clinical practice and includes research, education and training, and advocacy initiatives to promote context-specific, evidence-based initiatives to public health problems. Promoting and championing FAF serves as an example of the far-reaching, impactful role that neurosurgeons worldwide may play at the intersection of neurosurgery and public health.

Vitamin D deficiency is a worldwide public health concern, which can be addressed with voluntary or mandatory food fortification. The aim of this study was to determine if branded food composition databases can be used to investigate voluntary fortification practices. A case study was conducted using two nationally representative cross-sectional datasets of branded foods in Slovenia, collected in 2017 and 2020, and yearly sales data. Using food labeling data we investigated prevalence of fortification and average vitamin D content, while nutrient profiling was used to investigate overall nutritional quality of the foods. In both datasets, the highest prevalence of vitamin D fortification was observed in meal replacements (78% in 2017; 100% in 2020) and in margarine, corresponding to high market share. Other food categories commonly fortified with vitamin D are breakfast cereals (5% in 2017; 6% in 2020), yogurts and their imitates (5% in 2017; 4% in 2020), and baby foods (18% in both years). The highest declared average content of vitamin D was observed in margarine and foods for specific dietary use (7-8 μg/100g), followed by breakfast cereals (4 μg/100g), while the average content in other foods was below 2 μg/100g. Only minor differences were observed between 2017 and 2020. Major food-category differences were also observed in comparison of the overall nutritional quality of the fortified foods; higher overall nutritional quality was only observed in fortified margarine. Our study showed that branded food composition databases are extremely useful resources for the investigation and monitoring of fortification practices, particularly if sales data can also be used. In the absence of mandatory or recommended fortification in Slovenia, very few manufacturers decide to add vitamin D, and even when this is the case, such products are commonly niche foods with lower market shares. We observed exceptions in imported foods, which can be subject to fortification policies introduced in other countries.

Fish fortification with iodine-rich macroalgae (Laminaria digitata) and Selenium-rich yeast is expected to promote nutritional added value of this crucial food item, contributing to a healthy and balanced diet for consumers. However, it is not known if steaming can affect these nutrient levels in fortified fish. The present study evaluates the effect of steaming on nutrients contents in fortified farmed gilthead seabream (Sparus aurata) and common carp (Cyprinus carpio). Fortified seabream presented enhanced I, Se and Fe contents, whereas fortified carp presented enhanced I, Se and Zn contents. Steaming resulted in increased I and Se contents in fortified seabream, and increased Fe and Zn levels in fortified carp, with higher elements true retention values (TRVs >90%). The consumption of 150 g of steamed fortified seabream contributes to a significant daily intake (DI) of I (up to 12%) and Se (up to >100%). On the other hand, steamed fortified carp contributes to 19-23% of I DI and 30%-71% of Se DI. These results demonstrate that steaming is a healthy cooking method, maintaining the enhanced nutritional quality of fortified fish. Moreover, the present fortification strategy is a promising solution to develop high-quality farmed fish products to overcome nutritional deficiencies.

Numerous governments in developing countries institute school lunch programs or school feeding programs as a strategy to address high malnutrition and low education rates among children. In 2005, the Ghanaian government launched the Ghana School Feeding Programme (GSFP). The GSFP policy does not document (1) the actual meal and associated nutrient profile received by the student, (2) the cost of the meal ingredients to the caterer who prepares the food, nor (3) the recipe derivations that may supply an enhanced nutritional profile. We address these 3 information gaps by employing a detailed case study of 4 caterers supplying a traditional tomato stew recipe in northern Ghana within GSFP-supported school lunch programs. Specifically, we explore the following propositions: (1) GSFP caterers can deliver a school lunch for under 100 pesewas (1 GH¢ or $0.21 USD) per student; (2) the meal meets the recommended daily allowance for protein; (3) soy can serve as a cost-effective ingredient to fortify the meal in terms of protein level and protein quality; and (4) significant differences exist in the macro- and micronutrient profile due to caterer discretion. We answer the above 4 propositions, and by doing so show the importance of accurately measuring the nutritional content, costs, and quantities of the actual school lunch under study. Second, among our results, we show the economy of locally produced soy flour as an ingredient that can lower costs and raise nutrition when substituting for other locally produced proteins such as ground beef and mackerel.

Vitamin A (VA) deficiency is a serious public health problem, especially in preschool children who are at risk of increased mortality. In order to address this problem, the World Health Organization recommends periodic high-dose supplementation to children 6-59 months of age in areas of highest risk. Originally, supplementation was meant as a short-term solution until more sustainable interventions could be adopted. Currently, many countries are fortifying commercialized common staple and snack foods with retinyl palmitate. However, in some countries, overlapping programs may lead to excessive intakes. Our review uses case studies in the United States, Guatemala, Zambia, and South Africa to illustrate the potential for excessive intakes in some groups. For example, direct liver analysis from 27 U.S. adult cadavers revealed 33% prevalence of hypervitaminosis A (defined as ≥1 μmol/g liver). In 133 Zambian children, 59% were diagnosed with hypervitaminosis A using a retinol isotope dilution, and 16% had ≥5% total serum VA as retinyl esters, a measure of intoxication. In 40 South African children who frequently consumed liver, 72.5% had ≥5% total serum VA as retinyl esters. All four countries have mandatory fortified foods and a high percentage of supplement users or targeted supplementation to preschool children.

Fortified rice holds great potential for bringing essential micronutrients to a large part of the world population. The present study quantified the losses of three different micronutrients (vitamin A, iron, zinc) in fortified rice that were produced using three different techniques (hot extrusion, cold extrusion, and coating) and stored at two different environments (25 ± 5 °C at a humidity of 60% and 40 ± 5 °C at a humidity of 75%) for up to one year. Fortified rice premix from the different techniques was mixed with normal rice in a 1:100 ratio. Each sample was analyzed in triplicate. The study confirmed the high stability of iron and zinc during storage while the retention of vitamin A was significantly affected by storage and the type of techniques used to make rice premix. Losses for iron and zinc were typically <10% for any type of rice premix. After 12 months at mild conditions (25 °C and humidity of 60%), losses for vitamin A ranged from 20% for cold extrusion, 30% for hot extruded rice 77% for coated rice premix. At higher temperatures and humidity, losses of vitamin A were 40%-50% for extruded premix and 93% for coated premix after 6 months. We conclude that storage does lead to a major loss of vitamin A and question whether rice is a suitable food vehicle to fortify with vitamin A. For Cambodia, fortification of rice with iron and zinc could be an effective strategy to improve the micronutrient status of the population if no other food vehicles are available.