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Low calcium intake is common worldwide and can result in nutritional rickets in children and osteomalacia in adults. Calcium‐fortified foods could improve calcium intake. However, there is limited calcium fortification experience, with technical and practical issues that may hamper its adoption. The objective of this landscape review is to summarize these issues to help policymakers guide the planning and design of calcium fortification as a public health strategy. One challenge is the low bioavailability of calcium salts (∼20–40%); thus, large amounts need to be added to food to have a meaningful impact. Solubility is important when fortifying liquids and acidic foods. Calcium salts could change the flavor, color, and appearance of the food and may account for 70–90% of the total fortification cost. Safety is key to avoid exceeding the recommended intake; so the amount of added calcium should be based on the target calcium intake and the gap between inadequate and adequate levels. Monitoring includes the quality of the fortified food and population calcium intake using dietary assessment methods. Calcium fortification should follow regulations, implemented in an intersectorial way, and be informed by the right to health and equity. This information may help guide and plan this public health strategy. [ABSTRACT FROM AUTHOR]

Low dietary calcium is very common in many populations, contributing to nutritional rickets/osteomalacia in children/adults and increasing the risk of several health problems. Calcium is a nutrient of concern as the recommended nutrient requirements are difficult to meet in the absence of dairy products. The provision of culturally acceptable calcium‐fortified foods may improve calcium intake when it is a feasible and cost‐effective strategy in a particular setting. This landscape review was conducted in 2019 and describes current calcium fortification efforts and lessons learned from these experiences. Worldwide, the United Kingdom is the only country where calcium fortification of wheat flour is mandatory. It is estimated that this fortified staple ingredient contributes to 13–14% of calcium intake of the British population. Other items voluntary fortified with calcium include maize flour, rice, and water. Current calcium fortification programs may lack qualified personnel/training, clear guidelines on implementation, regulation, monitoring/evaluation, and functional indicators. Also, the cost of calcium premix is high and the target groups may be hard to reach. There is a lack of rigorous evaluation, particularly in settings with multiple micronutrient programs implemented simultaneously, with low quality of the evidence. Further research is needed to assess the impact of calcium fortification programs. [ABSTRACT FROM AUTHOR]