“Hidden hunger” — or micronutrient deficiency — affects over 2 billion people worldwide. It restricts children’s growth and well-being, robs them of their development potential, and slows the economic development of whole countries. Conversely, preventing hidden hunger can yield invaluable benefits.
“We need consumers and civil society to demand better diets and hold industry and government accountable.”
—Fortification of staple foods with essential vitamins and minerals is a proven, cost-effective, and sustainable way of reaching large numbers of people with vital nutrients. Large-scale fortification involves adding small amounts of vitamins and minerals to widely-consumed staple foods and condiments.
For certain micronutrients that are necessary for optimal development very early during pregnancy — such as folic acid — fortification can ensure a growing embryo or fetus gets essential nutrients even before a woman knows she is pregnant, or before she can seek prenatal care and take supplements.
The success of salt iodization
Staple food fortification as a public health program has been practiced for almost a century since salt iodization began in the 1920s. Salt iodization efforts accelerated after the 1990 United Nations World Summit for Children, which established the elimination of iodine deficiency disorders as a health goal.
Effective food fortifications
Adding vitamin A to oil and wheat flour improves children’s chances of survival by as much as 25 percent, strengthening their immunity to childhood diseases such as measles.
Fortifying flour and other food staples with Iron and B12 protects against anemia, a major cause of maternal death and decreased productivity. Folic acid protects against neural tube defects such as spina bifida, which can severely limit the quality of life for children and result in millions of dollars of additional health care costs.
Fortifying salt with iodine prevents brain damage and irreversible reduction to the IQ of young children.
Adding zinc to wheat flour prevents diarrhea and infections and promotes growth.
Today, more than 100 countries have national salt iodization programs and over 3 billion people use iodized salt. Six countries passed new legislation to mandate salt iodization between 2014 and 2017 alone. According to the World Health Organization, only 20 countries are still classified as having insufficient iodine intake, accounting for less than 7 percent of the 2018 global population — a dramatic shift from 110 countries 25 years ago and a public health success story of global proportions.
Salt iodization is credited with preventing 750 million cases of goiter — a swelling of the thyroid gland on the neck — over the past 25 years. Through a final push from donors and governments, the private sector, U.N. Children's Fund, Iodine Global Network, WHO, and other partners, iodine deficiency disorders can be eliminated globally in the coming four years.
Building on salt’s success
Today, more than 100 countries implement salt iodization programs. The good news is that in addition, 86 mandate at least one kind of cereal grain fortification, and over 30 legislate for the fortification of edible oils, margarine, and ghee.
“Lifesaving vitamins and minerals can be made available through fortified foods to billions of people around the globe who suffer from micronutrient deficiencies. This is a rallying call to key stakeholders.”
—But while many countries now have programs in place, data on the quality and coverage of fortified foods is limited. Recent estimates suggest that less than half of the foods marketed as fortified adhere to national standards. It’s time to think about moving the agenda forward.
Building on the 2015 Arusha Statement on Food Fortification, our new briefing paper sets out the unfinished agenda on food fortification, along with a five-step strategy to tackle it:
Advocacy, support to political processes, and capacity building to mandate new laws, expand national programs, and improve quality control and enforcement.
Support to ensure appropriate standards are set and technical assistance provided to enable compliance with standards.
Action to improve monitoring, research, and evaluation of programs.
Innovation to support solutions, such as technology to make monitoring simpler, and initiatives to build consumer demand.
Alignment of fortification and food safety programs.
What needs to happen next
Overall, there is an urgent need for more global and national accountability measures to enhance quality and compliance of fortification programs, as well as to stamp out fortification fraud. Preliminary assessments suggest that some 75 additional countries may stand to benefit from new public health programs to fortify foods with micronutrients including iodine, folic acid, iron, and vitamin A.
As well as the need for new national fortification programs and legislation to support them, many existing programs require updates to their fortification standards to align with global recommendations.
After the legislating and standard-setting comes the work of compliance to these standards: quality assurance, quality control, and monitoring, as well as introducing measures — incentives and deterrents — to achieve and sustain fortification of all fortifiable food in accordance with the national standard. Regular assessment of program quality, as well as a periodic assessment of coverage and impact, can provide much-needed data for decision-making on program improvement.
There are compelling reasons for assuring quality Consumers deserve authentic fortified foods and the government and industry must ensure fortified food fraud is mitigated.
Improvements in quality and compliance will come from boosting industry capacity to fortify, as well as government capacity and political will to monitor and enforce. Demand creation can also play a role — by making compliant fortified foods more affordable, available, and desirable.
A call to action
Lifesaving vitamins and minerals can be made available through fortified foods to billions of people around the globe who suffer from micronutrient deficiencies. This is a rallying call to key stakeholders.
Estimates suggest another $150-250 million from donors is required before 2030 to complete the food fortification agenda. So we need donors to increase commitment and funding. We need industry to better comply with legislation and ensure quality products are produced in line with standards. We need national governments to effectively monitor and enforce programs. We need consumers and civil society to demand better diets and hold industry and government accountable.
Adequate nutrition should not be a privilege in the 21st century. Sustainable Development Goal 2 aims for the end of hunger and malnutrition for all by 2030. Finishing the food fortification agenda must be a part of the solution.
To learn about a new partnership with actors Boris Kodjoe and Nicole Ari Parker to raise awareness of this issue, click here.
About the authors
Penjani Mkambula
Penjani Mkambula is global program lead for food fortification at the Global Alliance for Improved Nutrition. He manages the provision of technical assistance to GAIN programs focusing on reaching 1 billion people with fortified foods by 2022, as well as supporting other partners globally on food fortification His current project portfolio spans across public private partnerships, food fortification, food safety, and supply-chain management. Mkambula serves on the board of the Food Fortification Initiative and the steering committee of the Partnership for Aflatoxin Control in Africa.
Mduduzi NN Mbuya@Mdu_Rox
Mduduzi NN Mbuya is currently director of knowledge leadership, where he is responsible for research and evaluation at the Global Alliance for Improved Nutrition (GAIN). He works with colleagues to generate and use evidence to guide improved program design and implementation and to fill critical gaps in the global evidence. Mduduzi is a Zimbabwean national and has worked for over two decades on nutrition-sensitive programs and policy in LMICs.
Greg S Garrett
Greg S Garrett is the executive director at Access to Nutrition initiative, or ATNi. He oversees all aspects of the organization, including strategic collaborations with partners and stakeholders. Previously, Greg worked at the Global Alliance for Improved Nutrition, or GAIN, as director of food fortification and as director of policy and financing.
