Tackling a Hidden Pandemic: The Essential Role of Food Fortification

By Felistus Mutambi and Oliver Camp, Global Alliance for Improved Nutrition (GAIN)

Over recent months, the nutrition community has been working hard to mitigate against the COVID-19 pandemic adding fuel to the fire that is the hunger crisis. In fact, the WFP estimates that the number of people living in acute food insecurity could double by the end of 2020, so we must redouble our efforts to protect the most vulnerable.

As we do so, it is critically important that we focus not only on ensuring sufficient energy and protein, but also on ensuring the right micronutrients (i.e. vitamins or minerals) to fuel health and wellbeing. Unfortunately, the supply of nutrient-rich, vitamin- and mineral-loaded fruits, vegetables and other nutritious foods like eggs and dairy, has been under strain.

Meanwhile, twin economic challenges of job losses and rising food prices have left many more consumers unable to afford enough of these micronutrient-dense products.In this context, food fortification has become even more critical in the fight against malnutrition.

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Food fortification is the practice of adding essential micronutrients to foods that are widely consumed by the general population or a target group. It is a proven, cost-effective public health intervention that can reduce micronutrient deficiency, often termed ‘hidden hunger’, at scale, including among the poorest and most vulnerable.

Providing the nutrients needed for growth, development, and the maintenance of healthy life has enormous, long-term positive impacts: improving health and wellbeing; protecting against anaemia, stunting, and a whole host of other medical issues; and enabling proper physical and cognitive development among children and adolescents.

Universal Salt Iodization is often cited as a fortification success – providing iodine to vast numbers of people around the world over many decades, including here in Africa. And parts of Africa have made progress in the implementation of various fortification programs over the last 20 years through multi-stakeholder partnerships, enriching widely-consumed foods like wheat, maize, salt and edible oils with essential micronutrients such as iron, iodine, vitamin A, folate (vitamin B9) and zinc.

Status of Fortification in Sub-Saharan Africa

The Global Food Fortification Data Exchange, available online at https://fortificationdata.org/, is an analysis and visualization tool for data on food fortification, developed through collaboration of multiple partners (Micronutrient Forum, Iodine Global Network, the Global Alliance for Improved Nutrition & Food Fortification Initiative).

The data and visualizations can provide insights into the status of fortification regulation (including whether it is mandatory or voluntary), the existence of standards for fortification, and the micronutrient levels established in the national standards of each country.

Taking Burundi as an example, data from the GFDx platform reveal that legislation has been in place since 2015, making the fortification of maize and wheat with 9 micronutrients mandatory, with specific standards set to adhere to. Oil fortification is also mandatory, while salt fortification has been mandatory for almost 30 years (since 1992). Rice is not included in the fortification program.

Zooming out to the macro view, we see that 10 countries out of 46 in sub-Saharan Africa have mandatory fortification in place for maize flour, 20 for oil, 44 for salt, and 26 for wheat flour. This legal basis is a fantastic first step to implementing successful fortification programs.

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ChaLLENGES: Why Fortification Falls Short in sub-Saharan Africa

But it is only the first step. Once this legislation is in place, there is still plenty of work to do across the public and private sector.

In 2015, GAIN conducted a survey in 25 countries where GAIN-supported staple food fortification programmes had been implemented. The results of external quality assurance and quality control activities reported that compliance levels were around 45-50%. This estimate is consistent with other reports from programs and the published literature, and reflects a systemic compliance issue. Clearly, fortification is falling well short of its potential as a public health intervention.

There are several challenges that hinder the success of fortification programmes, ranging from industry non-compliance or technical mistakes in the fortification process leading to unfortified or under-fortified foods reaching consumers, through to the government’s inability to enforce fortification.

Overall, the seven key issues that hinder the adoption of fortification in the African context (often experienced elsewhere, too, as highlighted by GAIN’s article The Unfinished Agenda for Food Fortification) are:

  • Non-existent or insufficient legislation on mandatory fortification of staple foods. The lack of legislation creates an uneven playing field for business.
  • A lack of clear governance and coordination structures. Nutrition interventions can fall between the cracks when multiple agencies are responsible for related areas such as health, agriculture, food safety and trade. As the saying goes: when it’s everybody’s responsibility, it’s nobody’s responsibility. There is a need to revitalise the national coordination mechanisms for food fortification (e.g. National Fortification Alliances).
  • A focus on providing calories through staple foods like maize, rather than diverse, balanced diets complete with essential micronutrients. When people are food insecure, attention is paid to making sure that people have something to eat, not that it’s nutritionally optimal.
  • A lack of technical capacity, knowledge, infrastructure and resources across industry (especially small-scale producers) and government to enable proper implementation of fortification, industry compliance, effective quality monitoring and enforcement of fortification mandates
  • A lack of incentives to make a clear business case for fortification.
  • The availability of data on quality of fortified food, including coverage and consumption data, which limit the monitoring of progress and identification of corrective actions.
  • Premix supply chain issues, which can lead to an unreliable supply of vitamin and mineral ‘premixes’, or the prevalence of cheaper, lower-quality alternatives from non-approved suppliers.
  • National budgets are also often stretched, putting a squeeze on funding for fortification programmes; an issue that has been exacerbated during the COVID-19 pandemic, which has put unprecedented strains on budgets across governments, donors and development partners.

Twin economic challenges of job losses and rising food prices have left many more consumers unable to afford enough of these micronutrient-dense products. In this context, food fortification has become even more critical in the fight against malnutrition.

Solutions: Tapping the Full Potential of Fortification

These systemic challenges are complex and multifaceted but can be overcome through coordinated action. Development partners including GAIN are instrumental in helping governments and industries to make the most of fortification as a public health intervention.

  • Advocacy: first and foremost, securing mandatory legislation is key to the success of any fortification program. GAIN’s offices in Ethiopia, Kenya, Mozambique, Nigeria, and Tanzania work closely with governments to develop policies, regulation, and standards for fortification.
  • Evidence generation & use: creating and sharing information on the effectiveness of fortification programmes (including via platforms like the Global Fortification Data Exchange) can help to engage stakeholders and inspire and enable them to implement fortification programmes
  • Actions to improve monitoring, research, and evaluation of programmes: GAIN intends to provide technical support for the methodological, and information systems capacity that countries may require to assess fortification quality at the industry and market levels.
  • Technical support: GAIN provides technical guidance and training to government authorities, regulators, food standards agencies and private sector organisations. This is to ensure that all actors in the fortification value chain know how to fortify and test for fortification accurately and efficiently.
  • Procurement: GAIN provides technical, administrative, and financial support to governments and the private sector to streamline the procurement of key fortification inputs and equipment.
  • Increasing the availability and affordability of fortified nutritious food by supporting small and medium scale food processors to increase their distribution through innovative approaches.

Future Opportunities

First and foremost, there is still enormous scope for the wider adoption of fortification mandates across the continent.

Looking at data from GFDx, 26 countries have mandatory legislation for wheat flour, 10 countries (mainly in East and Southern Africa) have mandatory legislation for maize flour, 18 for oil (the majority in East & West Africa), and 44 countries have mandatory salt iodization. Aside from the fortification of maize, wheat, oil and salt, rice fortification – yet to be mandated in a single African nation – is an emerging opportunity with huge potential for impact at scale.

Ensuring industry compliance to standards and proper regulatory monitoring and enforcement will be the next step, bringing adequate micronutrients to hundreds of millions of people.

There are specific interventions that will also accelerate progress in the short- to medium-term, with long-term impacts. Therefore, we call for the following steps to be taken:

  • For governments to use fortified foods and condiments in social protection programme
  • For governments to protect and maintain fortification mandates, monitoring and surveillance protocols during the pandemic and into the future
  • For development organisations, governments and the private sector to support the food industry to improve COVID-19-safe operating procedures, quality assurance systems and equipment maintenance, with well-trained personnel for sustained production and distribution of fortified foods

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