The overall goals of this study were to explore and evaluate: (1) whether fluoridated salt would be acceptable to a low-income rural migrant Latino community in the US, and (2) how domestic salt use, cultural beliefs and experiences would help shape and influence acceptability.

Let us be clear. We did not set out to nor did we undertake a dietary survey to determine if current nutrient intake, water consumption or oral health habits resulted in adequate exposure to fluoride. Our concern was solely to identify and understand social and behavioral facilitators and barriers to acceptance of any potential salt fluoridation program. Before any such future program could be implemented, considerable nutritional research would first be necessary to establish current fluoride intake levels for people of all ages in this and similar communities to ensure that over-exposure to fluoride and its consequences would not occur. That is a very different study to this one, far beyond the scope of work reported here.

To address the social and behavioral questions surrounding acceptability of salt fluoridation, we undertook formative qualitative (ethnographic) research of Latino parents with children under age 10 in the same rural community in California's Central Valley where we had previously worked [13, 26, 31–32, 52–55]. Results from our previous work are consistent with those from other studies in general and on oral health, conducted with similar populations in other parts of the United States [56–59].

California is a major agricultural state with high proportions of Latino migrant and non-migrant farmworkers in the population, and so it served as a good place in which to situate the study. Like migrant farmworkers generally, in addition to oral health problems, people in this community experience a range of acute and chronic illnesses, some of which are directly associated with agricultural occupations, some of which may be exacerbated by (excess) dietary consumption of salt [60–65]. Besides oral health problems, other prevalent health conditions include musculoskeletal problems, diabetes, cardio-vascular disorders, skin diseases, depression and other mental health conditions, [60–65].

The community’s permanent resident population of around 11,148 is 97 percent Latino-origin, comprising mainly recent and a few second-generation immigrants, mostly from Mexico and other Latin American countries [64]. Non-livestock agriculture is the main economic enterprise, especially the growing of cantaloupes, tomatoes, asparagus, and other vegetables. For the period 2010–2013, which encompasses data collection for this study, approximately half (46%) of the 2, 884 households were at or below the US 2010 federal poverty level [66], partly due to high seasonal unemployment as well as the current drought.

This small city hosts a Federally Qualified Health Center providing primary care and basic medical emergency services, and an attached dental clinic. There are two other private general dentists in this city, and more than a dozen dentists in neighboring communities within a 30-mile radius [52]. The community does not add fluoride to its water supply. In 2006, the natural fluoride level of the water was 0.6ppm on average [13], slightly below the optimal level (0.7ppm). The vast majority of the population (95%), however, reported purchasing filtered or bottled water at $1.00/gallon and not consuming the available tap water for drinking; about half noted they use municipal water when cooking [13].

Primary research questions governing the data gathering activities in this study were:

Given these research questions and overall goals, an ethnographic approach was used to explore this under-studied topic, through use of qualitative interviews, focus groups and observations. Fig 1 (Fig 1) depicts the overall research process through three distinct but connected ethnographic stages.

Responses to the questionnaire provided basic insights into interview and focus group participants’ socio- demographics, self-reported health status, and salt habits. The total of 61 participants were predominantly low-income Spanish-speaking residents in the study site, most of whom were engaged in farm work or its associated industries, such as in canning or packing factories or in produce distribution such as in truck driving (details in Table 1).

It was easy to locate and purchase salt in this town that hosted four small- to medium-size full-service grocery stores, none of which was associated with a regional or national chain. In addition, there were 14 mini-mart or small convenience stores (bodegas), most offering a limited selection of packaged and fresh food along with household products or hardware items. An inventory was made (name, location, main menu items) of all 19 fast-food outlets, taco trucks, pupuserias, and quick service sit-down coffee shops/restaurants that sold prepared food or meals. Conversations were held with store and restaurant managers about their salt purchasing habits and their use of salt in locally made foods.

A few small stores did not sell salt at all, providing only items on the WIC approved food list. Every other retail establishment sold several brands of iodized salt along with smaller quantities of non-iodized salt. Table salt was sold mainly as a fine-grained pouring salt but larger granule sea salt or kosher salt was also available in the larger stores and used in cooking. Most popular with customers was a major US national brand with an easily recognized label, sold in 735 gram (26oz) canisters. Six other brands were available (two of which were imported from Mexico) especially in the small mini-marts or bodegas. Both iodized and non-iodized forms of salt were routinely available; it was possible on a few occasions but not routinely to purchase Mexican-origin salt that was both iodized and fluoridated. These packages were labeled in Spanish as containing both iodine and fluoride. Brands and types of packaged salt available in the larger stores were determined by the wholesale distributors rather than by specific request from the store manager. Also available, especially in convenience stores, were small salt-and-pepper shaker combination packs, a popular item in the lunch boxes of fieldworkers.

The volume of salt sales was extremely variable. Larger stores reported generally selling between 10 and 24 canisters per week whereas in the mini-marts and convenience stores, salt sales ranged widely, from one canister per month to two per week. Container labels clearly noted whether or not the salt was iodized in writing (usually in English, which many participants could not read) and by label color and specific visual emblems. Only three of the 28 individuals interviewed about this topic were aware that salt comes in both iodized and non-iodized forms. Two people said they had heard of fluoridated salt. Most did not know why salt contained iodide or fluoride additives. Salt purchases were made mainly by brand loyalty or package recognition or, to a lesser extent, by price. Even though salt was relatively inexpensive, ranging between a low of 59¢ per canister (or when on sale, two cans for $1.00) to a high of $1.49 per kilogram bag, a few participants reported always seeking the cheapest available and stocking up when salt was on sale.

Participants varied greatly in their salt buying habits. The majority (18 of the 30 Stage 2 interviewees, 60%) reported frequently purchasing salt, generally buying a canister 1 to 2 times per month; 4 of these 18 people bought a canister of salt each week. While two people (2 of 30, 7%) reported buying salt as infrequently as once or twice year, the rest (8 of 30) bought 3 to 6 canisters per year. Some of this variability comes from different household sizes, and some may result from people using table salt for purposes other than cooking. For example, field hands reported soaking their feet in warm salted water to soothe tired or painful muscles. We did not ask participants to estimate the proportion of salt that went for food preparation or consumption versus other uses.

The amount of salt purchased depended not just on household size but also on the number of home cooked meals being prepared, the number of people being fed at each meal, and the desired /acceptable taste of the food. Most participants noted that they generally ate at home and helped prepare or cook all (three) daily meals. The vast majority of participants (91%) reported using ordinary table salt rather than any kind of salt substitute. While two-thirds of the sample said they used salt during cooking only, about a half of the participants acknowledged that at least occasionally they also added salt at the table while eating. The mean weight of salt added to bean pot during that exercise was 19.2 grams (± 10.6grams; range = 2.4–60.3 grams; median = 17.4 grams), equivalent to 3.4 teaspoons. This amounts to approximately 2 grams per serving of cooked beans—a very significant proportion of the recommended daily intake of 2,300 milligrams of sodium (about a teaspoon of table salt per day) [75–76]. Men more than women tended to purchase and consume food outside the home. Beans, rice, chicken, soups, bread, pizza, prepared meats (such as hot dogs or chorizo sausage), sodas and sports drinks, were commonly consumed foods. These and other frequently used commercially produced, processed foods, (eg, bouillon cubes, ramen noodles) contain high levels of salt.

These comments and suspicions about the safety and general merits of substances added to some types of salt, led to discussion about adding fluoride to table salt. Similar to previous reports for this town [13], participants were generally not familiar with fluoride. For those who had heard of fluoride, most got their information from taking their children to the dentist; a few had noticed fluoride listed as an ingredient on toothpaste labels. Most were unaware, however, of its value in dental caries prevention. The few who were familiar with the term claimed it was for cleaning, whitening or protecting the teeth, or for protecting bones. A small number of participants recognized that their children had been prescribed fluoride drops or tablets by dentists or physicians and felt that fluoridated salt would be an easier, cheaper and safer way to provide a caries preventive to their children. This focus group discussion illustrates these points.

<Interviewer 1> And so now we are going to talk about the salt with fluoride. Have you ever heard about salt with fluoride?

<Respondent 8> Salt with fluoride?

<Interviewer 1> Um-hum.

<Respondent 8> I’ve heard about fluoride, that tooth paste have them right?

<Interviewer 1> Tooth paste, yes.

<Respondent 8> But not that it’s mixed with salt.

<Respondent 9> Not me neither, with water yes, but with salt.

<Interviewer 1> Or do you know what fluoride is for? Like [G] said it’s what they add to the tooth paste, so for what do you think…?

<Respondent 9> Isn’t it to whiten?

<Respondent 8> To whiten your teeth, no?

<Respondent 2> To build resistance and to whiten your teeth according to what they say, to have them [teeth] healthier.

<Interviewer 1> And where did you hear that?

<Respondent 2> At the same clinic here.

<Respondent 4> At the dentists.

<Respondent 2> At the dentist with my son, because I have a son who has cavities and they are giving him pills, but they are fluoride pills and they told me it was for him to chew them so that the gums could absorb it.

<Interviewer 1> Oh.

<Respondent 2> If the gums don’t absorb it when he [child] chews, they [pills] are fluoride he [dentist] said, if they [gums] don’t absorb it, and he [child] swallows it, the body will absorb it anyways, like a vitamin, but they are special for his teeth. The fluoride is stronger.

<Interviewer 1> Oh. Have you heard anything else?

<Respondent 2> There at the dentist is where I’ve heard the rest.

<Respondent 6> Yes, me too.

<Interviewer 1> Yes? Also about the pills? Or about something else?

<Respondent 4> No, just about the tooth paste and all of that and for the cavities, the fluoride.

<Interviewer 1> For cavities?

<Respondent 4> To clean them, like when the kids have cavities, tartar, all of that cleans it.

<Respondent 2> Yes.

Only one individual, a recent migrant from Mexico, recognized or mentioned knowing about fluoridated salt even though it is readily available and widely used there. This participant had been a cheese maker and knew how iodized and fluoridated salt affected the preparation and appearance of prepared foods. Another woman, Respondent 2 in the focus group excerpt below, might have been referring to fluoridated salt when she explained that children needed salt. She comes from Michoacan, a Mexican state where salt fluoridation is commonly used as a caries preventive [77]. What this conversation mainly reveals, however, is that while she remembers being taught that salt was good for her children, she does not remember the exact reasons why.

<Respondent 4> Salt is salt, and it affects you all the time.

<Interviewer 1> Or if you start to eat too much salt when you are an adult?

<Respondent 4> I feel that the salt is bad.

<Respondent 2> When the kids are small, like I told you, they need it, if they eat it in excess since they’re small, well it’s going to affect them, but if they eat the salt with moderation because they need it, then I don’t think is harmful. Until a certain age when they begin to grow if they continue to eat too much salt, then it starts to affect them, but kids a little bit of salt that they eat, that’s good for them. Because there in Mexico they tell us ‘Kids need to eat salt in their things because it’s good for them, they need it.’ I don’t remember what the salt had which is good for them. And that’s why I say that as long as the kids are fine, are developing…

<Interviewer 1> Which part of Mexico, did you say?

<Respondent 2> Michoacan, there, I’m from the central Michoacan. In the health center that’s where they told us. They told us that the kids needed to, how do I tell you? have to eat salt. They gave us talks. They have to eat salt because they need it, it is good for them for their gums, their teeth, all of that. That’s why I don’t think, unless here they say no, but they said that over there.

Most people initially said they would not use fluoridated salt until they better understood what fluoride did and why it was important. They were adamant about their need to be clearly and completely informed and assured first of its taste and safety, especially with respect to their children’s health. They also pointed to physicians, dentists or nurses as trusted sources of information who would provide them with reliable, authoritative information about fluoride.

One study participant noted:

<Interviewer> Have you ever seen one of these containers that says salt with fluoride?

<Respondent> No, or I haven’t paid attention.

<Interviewer> Would you grab one of these containers?

<Respondent> Not until I was sure what benefits it has.

while another participant commented:

<Interviewer> Or what type of information would you need in order to be interested in grabbing a container that said salt with fluoride?

<Respondent> Well, if I was better informed I would take it, that’s why I’m used to taking what I already know. That’s why I say I never change seasonings; look here it has one, because I already know these ones.

Yet another stated clearly:

<Respondent> Well, depends on what they say, that that salt is good for your body that it doesn’t contain, well that it doesn’t harm the bones, things like that, well people might get excited to buy it.

A fourth interviewee lays out her safety concerns in even more detail:

<Interviewer> So what would convince you to buy it? What would the tin have to have or…

<Respondent> To know what it contains, to know what the salt would contain, if it doesn’t affect the bones, or teeth or the ears, the hair, have you seen how many lose their hair? So that is why I tell you, you heard something mentioned, but if you don’t know what it contains then why would you buy it?

After the interviewers provided information and answered their questions about fluoride’s purpose and safety, most respondents reported a strong inclination to accept fluoridated salt if it were available. For participants with young children, the major incentive for acceptance was the benefit fluoride would confer on their children’s health, specifically their oral health. In answer to the question “Who would benefit the most by having access to fluoridated salt?” more often than not the first answer was ‘the children.’

<interviewer> And would you use this salt with fluoride here with your family?

<respondent> Yes.

<interviewer> Why?

<respondent> Well, because of the fluoride, too. So that it’d help to strengthen my children’s teeth.

But when probed further, the majority said that everyone would benefit from fluoridated salt, children, adults and seniors. One interviewee said: “Whoever has teeth, evenly, because that doesn’t help those of us who don’t have teeth. …” Another participant expanded on this theme “Because old people, children, adults… we all have teeth. We all have caries and we all lose everything, our teeth. Well, yes. But for children, to protect them, to start protecting them, right?”

Besides the benefit conferred, other factors played key roles in acceptability. In relation to currently available table salt, fluoridated salt also had to look and taste the same, perform in the same fashion during cooking, be as easily obtained in the same grocery stores, and have at best a very modest cost increase Most participants reported that they would seriously consider paying a little more for fluoridated salt if it were safe, beneficial to their children’s or grandchildren’s teeth and had the same taste qualities as currently available table salt. Taste was the paramount consideration.

When asked to predict its acceptability to their families, it became very clear that women who cook are the primary decision-makers, controllers and overseers of family diet and health. For the most part, women in the study said that if fluoridated salt tasted good, they would accept fluoridated salt, as the following conversations reveal.

<Respondent 6> Oh, okay, well then I would try it to see how it went with the ‘lawyers’ I have.

<Interviewer 1> If they like it or not?

<Respondent 6> I don’t have lawyers but it’s as if I had them.

<Interviewer 1> Oh.

<Respondent 5> I think…

<Respondent 6> ‘It has too much salt, it has too much fat, it has too much this.’ And I tell them ‘And it also has too much “madre” as well. If you want to eat it, I’m sure you’ll eat it’

<Interviewer 1> So it depends a lot on the taste?

<Respondent 6> Yes, for me.

<Interviewer 1> The taste? Okay. And what do you think?

<Respondent 5> I would also use it but I would make a meal, if it was in the morning.

<Interviewer 1> Um-hum.

<Respondent 4> I’m going to use it when I make my breakfast, lunch and I’m not going to tell them anything. I’m the one who is going to know if I’m going to add it, so I’m going to see if anyone says…

<Interviewer 1> So see if there is a complaint.

<Respondent 4> To see if there is one person who notices the difference right? ‘What did you add today to the breakfast that it’s more delicious?’ Or something. If it’s just like ‘Oh my stomach hurts!’ Or I don’t know something like that that they mention then perhaps it’s because of that. But I’m the one who is going to think and then I’m going to explain to them what it was, what it is.

Women in another focus group had a similar discussion:

<Interviewer 1> …. So first you would try it?

<Respondent 4> First I would try it one day and then…

<Respondent 1> I think I would do the same.

<Interviewer 1> Really?

<Respondent 1> Because I don’t know, I’ve never tried that brand or anything but if it’s for my health and it is good for my family, I would use it.

<Interviewer 1> Really? And it depends on the taste?

<Respondent 1> Yes, aha.

<Interviewer 1> If the flavor changes, then no?

<Respondent 1> No, if I see that’s good for my family I would use it.

<Interviewer 1> Oh.

<Respondent 5> If it’s good for my health, I would use it.

<Respondent 4> They [health experts] should make it known first ‘Look there is this, it has this, it has this.’ And well if they say “it’s good for your health” then you have to take it.

<Respondent 3> I would use it the same way as the normal one because my family doesn’t even realize what brands I use of anything.

<Respondent 2> It’s the same in my case.

<Interviewer 1> It’s the same thing, no?

<Respondent 3> Yes.

<Respondent 2> I’m the one who cooks and that’s it. I would add it and I wouldn’t tell them.

<Respondent 5> Yes, but they realize what we use. Even though they don’t cook, but they see…

<Interviewer 1> The tin.

<Respondent 5> What we take. Because they are grownups how are they going to say ‘no’, or ‘use another one’. Because even though they don’t cook, they say ‘Oh my mom uses this one.’ Or ‘She always takes this one.’ Like that, so that right?

This study is limited by its small convenience sample with a truncated income range, and a single rural location. Other limitations are lack of detailed dietary information, especially the daily intake of salt for various age groups in this setting. Caution must be taken when making generalizations especially to other Hispanic or migrant populations, other socioeconomic strata, or different geographic regions. Off-setting some of these limitations, however, is that the study site in California’s Central Valley and the demographic characteristics of participants are reasonably representative of rural US farmworker Latino communities generally [56–57]. Study findings about community beliefs and behaviors, and the implications of these for acceptability and adequate fluoride exposure through salt might therefore be applicable to other vulnerable Latino populations beyond this local context.

As one of few studies that have investigated the acceptability of fluoridated salt for caries prevention in a US community, this study makes a modest but valuable contribution. It is one of very few examinations of how children’s caregivers use domestic salt and understand its properties [78]. Parental perceptions and actions based thereon are highly influential in oral health care seeking for children in minority communities, such as a low-income, rural Hispanic communities, which often have quite distinct oral health beliefs, understandings and responses [26, 53–44,78], as well as a high prevalence of oral disease, especially among young children [12,19–20].

While this study suggests that fluoridated table salt would be acceptable to this and similar small, vulnerable rural Latino communities in the United States, the feasibility of providing fluoridated salt on a mass scale faces many challenges [34]. As noted in the Introduction above, before any future salt fluoridation program could be implemented, considerable nutritional research would first be necessary, regionally if not nationwide. Current fluoride intake levels for people of all ages in large and small, rural and urban, communities would need to be established to ensure that over-exposure to fluoride and its consequences would not occur. Dietary and other surveys would be needed to determine if current nutrient intake, water consumption or oral health and hygiene habits already result in adequate exposure to fluoride. Our study identified individual and community level social and behavioral facilitators and barriers to acceptance of any potential salt fluoridation program in just one type of community.

Barriers to developing a regional or national fluoridated salt program exist at many levels. Among these obstacles are: individual beliefs and values; household purchasing and consumption practices; ability to expand fluoridated salt use beyond the domestic sphere into restaurants, schools, residential institutions (eg., hospitals, prisons, military facilities) and other organizations operating large kitchens (eg., hotels); the availability and nature of supportive community assets including access to and use of fluoridated water supplies; access to and use of other fluoridated products; views and concerns of medical and dental professionals about daily salt (sodium) intake; development and deployment of effective public health education campaigns, and wide scale acceptance of fluoridated salt; monitoring to prevent over-consumption of fluoride; commercial salt and food manufacturing, distribution and marketing processes; and federal regulation and policy adjustments [79].

Despite sustained public health advocacy, there remains considerable suspicion of; resistance to and vocal advocacy against water fluoridation as a caries preventive and the use of fluoride generally [39, 80–81]. Though the scientific evidence for such claims is slim and controversial, many people continue to express a belief that long-term fluoridation leads to deleterious health consequences. Unlike fluoridation of municipal water supplies, which does not easily allow an individual access to a non-fluoridated public source of water, the production of fluoridated salt would not preclude the manufacture and distribution of non-fluoridated salt. Hence, purchase and use of fluoridated salt would be under the control of consumers and could be avoided if so desired. Nevertheless, attempts to introduce fluoridated salt could result in resistance, not just from anti-fluoridation groups but also from segments of the medical and oral health professions. There are legitimate concerns about possible increases in consumption of sodium if fluoridated salt were widely available and marketed as ‘beneficial to health.’ Increased sodium consumption would have undesirable impacts on cardio-vascular and other diseases [75–76]. There is also concern about possible over-exposure to fluoride and the development of dental fluorosis [39, 79, 82] although studies have generally found this to not be a major issue when optimal fluoridation levels are maintained [2, 5, 7, 79]. Some commentators point out that the effectiveness of water fluoridation has waned in recent times compared to its introduction decades ago. Part of the reason for this “halo” effect is the burgeoning of other fluoride-containing products (eg., dentifrices) and foods and drinks in the American diet [39, 51].

Distributors rather than storeowners or managers controlled the timing, quantity and brand of salt delivered to the rural stores in this area of California. Distributors would need to be aware of regional conditions. In a few areas in the United States (eg., specific areas in Colorado), water sources are naturally high in fluoride content, making fluoridation of municipal supplies as a caries (dental decay) preventive unnecessary. Commercial distribution and availability of fluoridated salt in these areas would also need to be restricted, as it is in Mexico where for the same reasons several western states are excluded from participating in that nation’s fluoridated salt program [77]. It can be difficult, however, to confine fluoridated salt to specific locales or patrol its transport across regional boundaries (see p. 54 of the American Dental Association’s publication [5] for an example from Basel, Switzerland).

In Hispanic communities that eschew use of municipal water supplies for drinking or cooking [10–15], over-exposure to fluoride may not be as large a concern as under-exposure in these communities where people are at high-risk for caries. Fluoridated salt could help alleviate under-exposure and boost caries prevention. Commercial salt would need to be monitored regularly to ensure adequacy and appropriateness of fluoride fortification. In Mexico City in 2008, for example, more than 40 brands of fluoridated salt were available, with a fluoride content that ranged widely, from 0 to 485ppm [77; cf. 39]. In other words, fluoride content ranged from complete absence to over-abundance, indicating poor quality control and monitoring. In addition to evaluating fluoride levels in various communal sources, such as water or salt, individual fluoride levels might also need regular monitoring. Those who regularly eat outside their home, drink commercially filtered water, purchase salt at stores outside their region, and use a variety of other fluoride-containing products could also experience variable exposure, making complex the control, monitoring and assessment of fluoride intake and adequacy at the individual let alone the population level [79].

The proportion of processed food in the reported daily diet of this rural Latino population was greater than expected. It has sometimes been suggested that low-income Latino farmworker families generally do not consume commercially processed or packaged foodstuffs, but these results suggest this is not necessarily the case [83]. In this study, commercially prepared items, including dietary staples, were purchased and used on a regular basis. Many of these items—such as bouillon cubes, freeze-dried or ramen noodle soups as well as breads, sausages and hot dogs, pizzas, sports drinks—tend to have a high sodium content [83–86]. In a 2013 report on obesity, The Hispanic Institute argued that the processed food industry should be held accountable for “its complicity in flooding stores with drinks that are too sugary and foods that are too salty and fat” [87].

Salt used in the commercial preparation of canned items is not iodized because chemical reactions that occur during the cooking and preserving of many foods, especially vegetables, lead to undesired color changes rendering the food generally safe to eat but visually unappealing. Use of salt other than sodium chloride can make some pickled or fermented foods unstable or unsafe to consume [35, 88–89]. For similar reasons, it is unlikely that fluoridated salt would be incorporated in the commercial canning and processing of many foodstuffs. This could reduce the extent to which salt consumed on a daily basis in rural Latino households would provide oral health benefits to the population.

At present, commercial manufacturers in the US produce iodized salt on a voluntary rather than a legislated basis [34–35] but there is little incentive for manufacturers to voluntarily add sodium or potassium fluoride to domestic salt. Following very strong public health campaigns in the 1920’s, iodized salt to combat thyroid disease became not only available but normative nationwide in the US [34]. Prior to this, thyroid disease led to extensive disability and death. Without a similar concerted public health campaign about the health impact of caries, which though an extremely common condition is rarely fatal, fluoridation of salt is unlikely to occur. While the amount of sodium or potassium fluoride (NaF or KF) that would need to be added, 200–300mg F per kg of salt, costing about US$0.015 to US$0.030 per capita/year[39], is relatively small and cheap, the technical processes of monitoring and ensuring safety would not necessarily be inexpensive [34]. If monitoring and safety costs were passed along to the consumer, it could result in decreased sales of some brands of domestic table salt because of increased competition from other cheaper (non-fluoridated) brands.

A first hurdle to address, however, could be federal regulation. Existing rules would need to be evaluated and possibly amended to accommodate—or possibly even to mandate—commercial production and distribution of fluoridated salt. The Federal Register [90] describes the current ruling on fluoride and food additives as:

Whether importation on a large scale of fluoridated salt from Mexico where it is already commercially produced and distributed, could resolve some feasibility issues is unclear. Globally, a variety of political alliances, trade partnerships and agreements exist regarding the regional manufacture and distribution of various fortified consumable products [34, 91] but none of these agreements was achieved easily or quickly. Existing or revised trade agreements between Mexico and the United States might comprise other barriers or, alternately, might facilitate access to widespread marketing and distribution of this proven caries preventive.