Multisector partnerships: Crucial to achieving adequate food fortification

The Guatemalan Alliance to End Hunger works with the Ministry of Public Health to distribute a fortified drink mix to families at risk of malnutrition. Photo by: Alliance to End Hunger / Bread for the World / CC BY-NC-ND

Poor nutrition is one of the biggest global challenges of our time. Today, hundreds of millions of people still suffer from micronutrient deficiency, otherwise known as “hidden hunger.” While hidden hunger rarely shows visible signs in those who are affected, its consequences can be disastrous, leading to poor physical and mental health, increased child and maternal mortality and reduced cognitive development.

Food fortification — adding small and safe amounts of micronutrients to staple foods and condiments — is a simple, scalable and highly cost-effective development intervention that is reaching billions across the world.

The example of flour fortification

The fortification of flour with multiple micronutrients (including zinc, iron and folate) can help to alleviate some of the most common micronutrient deficiencies of great public health and economic concern.

#FutureFortified: How food fortification can help end micronutrient malnutrition

Food fortification is reaching billions across the world through its simplicity and scalability. In this guest column, GAIN's Greg S. Garrett writes how, possibly for the first time, all the major players in micronutrient fortification are aligned around a common set of issues that need to be addressed.

Zinc helps strengthen the immune systems and lessens complications from diarrhea, the number one killer of children under 5 in low- and middle-income countries (directly through dehydration and indirectly through preventing the absorption of essential macro and micronutrients). Iron and vitamin B complex (especially B12) prevent nutritional anemia, which improves productivity, maternal health and cognitive development. Folic acid reduces the risks of neural tube birth defects, a defect in the development of the spinal cord that can lead to lifelong physical and cognitive disability.

The solution is quite simple and inexpensive: adding these essential micronutrients to flour, one of the most widely consumed staple foods across all socio-economic groups. The implications of this for diseases prevention, improved productivity and increased economic potential are enormous and require relatively low levels of investment. If we look at the example of flour fortification, it costs an estimated $0.12 per person per year to fortify wheat flour with iron and as little as $0.06-$0.24 per person per year to fortify wheat flour with zinc. These costs are minimal compared, for instance, to the cost of treating children with spina bifida and immeasurable impact on families. It is estimated that fortifying flour with folic acid contributes to health care savings of $2.3 million in Chile, more than $3 million in South Africa and $603 million in the U.S. Moreover, fortification costs can easily be recovered through sales of “value added” product in the markets.

Fortification is not only cost-effective, but also impactful. Where flour fortification is mandatory, countries have experienced between 31 and 58 percent reductions in neural tube birth defects or neglected tropical diseases. Global NTDs prevalence is around 24 in 10,000 births, but typically it drops to below 10 in 10,000 births after fortification with folic acid.

The role of the private sector

The private sector — especially millers and producers who fortify — are the gatekeepers to the nutritional health of the populations in their distribution network. It is therefore critical for the private sector to fully engage in the fortification process and to ensure that quality control and good manufacturing practices are in place. This will allow households to consistently have access to high quality, safe and adequately fortified foods.

GAIN’s approach to a #FutureFortified

Through developing large-scale food fortification programs, GAIN has proven that multi-stakeholder partnerships — when governments, civil society and business work together — are critical to success. These National Fortification Alliances enhance communication and collaboration, creating an enabling environment for support and advice on the process. Through these alliances, GAIN serves as a technical adviser to food industries, as well as a partner to governments to improve the quality and monitoring of fortified foods.

GAIN’s work to fortify staple foods and condiments with essential micronutrients reaches more than 1 billion people in 40 countries worldwide. GAIN-supported flour fortification programs have helped reduce neural tube defects in South Africa through flour fortification with folate and iron deficiency anaemia in Nigeria, Jordan and Morocco through flour fortification with iron.

It is estimated that currently, in low- and middle-income countries, less than 50 percent of products claimed as “fortified” are adequately fortified to the levels indicated in their respective national standards. These include countries where food fortification is mandatory by law and where businesses receive support or incentives to fortify.

Enforcement and compliance need to be strengthened to ensure the effectiveness of fortification programs and there is a strong need for the private sector to be the driving force for this change. Food fortification should be seen as an opportunity for industry to demonstrate corporate social responsibility and may at times provide industry a competitive edge.

For example, Urbano Rice — one of the leading rice millers in Brazil — noted compelling business opportunities in developing a fortified product, including competitive differentiation in a flat growth market; brand-building as an innovative and socially conscious company and expansion of the product line into export markets (Costa Rica and Peru, for example).

In 2010, Urbano launched a partnership project with the Global Alliance for Improved Nutrition and PATH to introduce affordable multiple micronutrient fortified rice in the Brazilian market, while raising awareness of the benefits of fortified products. Urbano consequently embraced fortification as part of its marketing strategy, co-investing substantially in store collateral, tasting booths, and other marketing materials to promote the product.

Through innovative social marketing, awareness of fortified rice went from a very low level to almost one third of the exposed market in just 12 months. In terms of sales, fortified rice has shown consistent growth since its introduction and faster consumer uptake than comparable new rice subcategories in Brazil. Thanks to the great support of Urbano, this project has reached an estimated 2 million consumers.

While food fortification is not the only solution — dietary diversity and affordable access to nutritious foods remain crucial in the fight against malnutrition — it is a powerful tool that enables children to perform better at school, prepares mothers for healthy pregnancies and prevents diseases that burden health care systems. As the world population grows and urbanizes, the role of industrially produced foods that can be fortified will continue to increase. The challenge now is to achieve adequate and safe fortification across the board, otherwise people will continue to be left behind.

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About the authors

  • Corey Luthringer

    Corey Luthringer is a senior associate at the Global Alliance for Improved Nutrition. She has been a GAIN consultant on a variety of projects since 2014, working primarily within large-scale food fortification and issues of improving fortified food quality and regulatory monitoring. Since 2012, she has studied and consulted with various global health and nutrition organizations in Latin America, South Asia, Europe, and Africa, including BRAC in Bangladesh and the U.N. World Food Program in Italy and the regional bureau in Egypt, where she specialized in emergency nutrition and resilience building.
  • Beatrice Montesi

    Beatrice Montesi is an external relations associate at the Global Alliance for Improved Nutrition. She currently oversees the implementation of the #FutureFortified campaign on social media to raise awareness for food fortification programs. Prior to joining GAIN, Beatrice worked at the U.N. World Food Program in Geneva, where she helped communicate the important humanitarian role played by the agency in emergency contexts. Beatrice is an international affairs specialist with a passion for food and nutrition security, women’s empowerment and global health.