Understanding hunger

Hunger — one of the most perennial calls-to-action in global development — is misunderstood.

“The images we use to [illustrate] hunger — the emaciated, starving child who hasn’t eaten for days or weeks — no longer capture the whole picture,” Bjørn Lomborg, director of the Copenhagen Consensus Center told Devex last month on the sidelines of the Global Alliance for Improved Nutrition #FutureFortified Global Summit in Arusha, Tanzania.

“Now we’re looking at loss of life and loss of potential caused by unseen deficiencies — deficiencies taken for granted in so much of the developed world where people don’t need to know their foods are fortified with nutrients in order to be saved by them,” he said.

Food fortification has long benefited from a lack of awareness, Lomborg explained. People don’t need to know why — or by whom — their flour is enriched with folic acid and vitamin A in order to see neural tube defects in newborns reduced by 30 percent over a single generation. Likewise, in only a few decades, 91 million children were protected against iodine deficiency, and not because consumers changed their habits, according to a study by UNICEF. Meanwhile, the fortification of cooking oil with vitamin A, which became mandatory in Indonesia in March, reduced vitamin A deficiency in infants and breast-feeding mothers without increasing the amount of cooking oil consumed.

When governments make fortification mandatory, as they have in one form or another in 84 countries across the globe, advertising and awareness campaigns become less necessary — saving time and budgets, as well as lives.

“Some of the biggest impacts happen because a few people decide to do things in regulation that nobody has any idea about,” Lomborg added, noting that fortification’s ability to fly under the radar earned its status as an unsung hero in global development.

But as with all interventions, global trends and new strides in the nutrition field call for a more nuanced approach to reach everyone who needs it, and fortification’s low profile has, in some ways, become its curse.

Refining what works

Rebecca Spohrer, international nutrition program manager at GAIN stressed that fortification needs the spotlight now, and that today’s interventions call for more nuanced coordination across development actors, governments and industry than previous fortification efforts in the developed world.

“We have to look at dietary gaps and micronutrient deficiencies in each country before making a decision whether or not fortification is a relevant intervention,” Spohrer said.

More coordination and targeted interventions are needed across sectors to accommodate the vast, global variety of diets, Shawn Baker, director of nutrition at the Bill & Melinda Gates Foundation told Devex at European Development Days 2015 in July. For example, in countries where flour consumption is low, governments, institutions and industry work together to advance the science of rice fortification. In many countries, cooking oil is easily fortified with vitamin A, but cooking at very high temperatures might deplete those nutrients in the process.

“There needs to be better data to drive which foods should be fortified and consumed by the people most at risk,” Baker said.

Diets and practices vary, so a cocktail of fortificants — in custom premixes, for example — could work well, but can’t be applied without coordination from all sectors and in many cases, more legislation and robust regulation of companies, which Baker and others argue is the next step to getting companies 100 percent onboard. This top-down approach to fortification — as opposed to a shared value approach — would level the playing field for companies, who might otherwise see little incentive to fortify.

Because while most interventions benefit from industry buy-in, Baker said, food fortification absolutely requires it.

“How do we get the right vitamins and minerals into those foods?” Baker added. “Mandatory regulatory environments.”

But even when the right laws are passed, Spohrer explained that companies don’t always keep their end of the bargain.

“Without producers, food doesn’t get fortified. Without strong government regulation — something many governments in developing countries don’t budget for — food may not get fortified correctly, because companies want to save money or don’t have the capacity,” she said.

The task now, according to Spohrer, is convincing governments to invest in regulation to hold them accountable — a challenge in environments where the impacts of food fortification have slid under the radar.

Processing stigma

Even where politicians and officials understand the benefits of mandatory fortification, the practice may still carry stigma or political risk.

“When elections are coming up in an impoverished country it’s difficult to get politicians to embrace an increase in flour prices even if it’s only 1 percent,” Greg Garrett, director of food fortification at GAIN told Devex.

“This is even when the price increase will be far outweighed by a nourished population, which can increase the [gross domestic product] 5, 6 percent or more,” he said.

And even among development professionals and the most well-informed nutrition experts, food fortification can get tied up with some unsavoury buzzwords and trends, namely urbanization and the growing consumption of processed foods.

As urban populations grow and access to fresh produce decreases, the trend toward higher consumption of processed foods is hard to deny, Spohrer explained.

“We need to be careful about this,” Spohrer said. “We are absolutely not, I repeat not, recommending that people in developing countries take on more of a Western diet and eat more processed foods.”

“But it’s happening,” she added.

In order to maximize the impacts of fortification, the practice must embrace current trends in order to reach the most people, regardless of the negative associations many have with processed foods. And with current technology and knowledge about nutrition, Garrett added, processing and fortification can be done responsibly and to the benefit of the population, even if the rhetoric is tricky.

Small producers and the problem of regulation

Advocates of food fortification are finding themselves on another slippery slope in the aid community.

The mandatory fortification movement, as it stands, favors medium-to-large food producers, rather than small and sustenance producers. Larger producers are more able to withstand the costs of mandatory regulation, Spohrer said, whereas smaller businesses risk failure under new regulations.

In that case, governments can — and do — let small producers off the hook.

“Most of the time when we talk about regulation and enforcement laws we’re only talking about applying them at the kind of middle to large-scale level,” Spohrer said.

Unfortunately, this leaves small and remote producers — sometimes the poorest in a population — without access to fortified foods and at highest risk for malnutriton.

“So we’re looking at alternatives to be able to encourage small-scale fortification and provide support rather than punishment,” Spohrer said.

While a more robust industry may eventually close the gaps as producers increase their reach to the remotest corners, Spohrer and others stressed that — with time — perfecting the balance between regulation, industry, and customized fortification will finally push malnutrition out of the aid spotlight.

Future Fortified is a special online series exploring the impact and importance of food fortification to meet global development objectives. Join Devex — and our partner GAIN — in the conversation using #FutureFortified.