28 Jan 2019

Let’s close the gaps on food fortification – for better nutrition

Sharada Keats Senior Associate, Policy and Advocacy, Global Alliance for Improved Nutrition (GAIN)

Over a quarter of the global population, more than two billion people, suffer micronutrient deficiency – also known as hidden hunger. This restricts growth and wellbeing, restricts children’s potential and slows economic progress.

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 foods and condiments. Fortifying salt with iodine, for example, prevents irreversible brain damage in young children, while fortifying flour with iron and folic acid helps protect against iron deficiency anaemia, a major cause of maternal death, and neural tube defects, respectively.

Fortification works

The evidence confirms that food fortification programmes in low- and middle-income countries improve a range of micronutrient deficiency-related outcomes. Large-scale food fortification has substantially increased the availability of nutrients – including iron, folate and vitamin A – in several regions globally.

The most striking success story is that of salt iodisation. Over six billion people consume iodised salt. It is credited with preventing 750 million cases of goitre over the past 25 years.

Over 100 countries have national salt iodisation programmes. Beyond this, 86 countries mandate at least one kind of cereal grain fortification, and over 30 legislate for fortification of edible oils, margarine and ghee.

A preliminary assessment by the Global Alliance for Improved Nutrition (GAIN) suggests that around 75 more countries stand to benefit from new public health programmes to fortify foods.

Identifying the food fortification gaps

Many countries now have programmes in place, yet data on the quality and household use of fortified foods is limited. Recent estimates suggest that only half of foods marketed as fortified adhere to national standards. While data is still patchy (as is the case with many nutrition interventions highlighted in the 2018 Global Nutrition Report), GAIN and its partners, including the Food Fortification Initiative and the Iodine Global Network, are working to help fill some of the gaps.

In 2013, GAIN developed the Fortification Assessment Coverage Toolkit (FACT) to generate much-needed information on the coverage and quality of fortified foods. Between 2013 and 2017, FACT surveys were conducted in 16 low- and middle-income countries.

The results have revealed that while in many places food fortification has high potential to reach vulnerable populations (including women and young children, those living in rural areas and those living in poverty), this potential is not presently met, owing to poor programme coverage and compliance.

Household coverage estimates are extremely useful for highlighting gaps in programme design and implementation (Figure 1).

Figure 1: Gaps in design and implementation of large-scale food fortification programmes

Source: Aggregated survey data, GAIN analysis. 
Note: Wheat flour data taken from 16 surveys, maize flour 8 surveys, oil/ghee 14 surveys, and salt 13 surveys for fortifiable salt, 21 surveys for fortified salt. For detailed results by country refer to Aaron et al 2017, Knowles et al 2017 and the PLOS ONE Fortification Assessment Collection.

Source: Aggregated survey data, GAIN analysis.

Note: Wheat flour data taken from 16 surveys, maize flour 8 surveys, oil/ghee 14 surveys, and salt 13 surveys for fortifiable salt, 21 surveys for fortified salt. For detailed results by country refer to Aaron et al 2017, Knowles et al 2017 and the PLOS ONE Fortification Assessment Collection.

The use gap represents the proportion of households in a population not consuming the food vehicle chosen for fortification. This gap highlights the extent to which foods that are widely consumed have been selected for inclusion in a programme.

The feasibility gap highlights the difference between the proportion of households consuming the food in any form and those consuming the food in a fortifiable and industrially produced form (that is, the potential proportion of households that could be reached by the programme if all fortifiable food was fortified.) This gap highlights the extent to which the programme was well designed, meaning it selected foods to fortify based on those that are used in a fortifiable form by a high proportion of households.

The fortification gap represents the difference between the proportion of households that consume the fortifiable food and those that consume it fortified. This gap highlights one element of effective implementation.

A fourth gap, not shown, can also be identified. This is the quality gap – the extent to which any fortified food consumed is fortified to national standards. Where these gaps are large, greater monitoring and enforcement may be needed.

GAIN’s five-step plan

Building on the 2015 Arusha Statement on Food Fortification, the Global Alliance for Improved Nutrition’s 2018 briefing paper sets out this unfinished agenda on food fortification, along with a five-step strategy to tackle it.

  1. Advocacy, support to political processes, and capacity building to mandate new laws, expand national programs, and improve quality control and enforcement.
  2. Support to ensure appropriate standards are set and technical assistance is provided to enable compliance with standards.
  3. Action to improve monitoring, research and evaluation of programs.
  4. Innovation to support solutions, such as technology to make monitoring simpler, and initiatives to build consumer demand.
  5. Alignment of fortification and food safety programs.

Let’s close the gaps

Donors, industry, national governments, consumers and civil society all have roles to play – in funding, compliance, monitoring, and in holding those responsible to account. Estimates suggest another $150–250 million from donors is required before 2030 to complete the food fortification agenda.

Sustainable Development Goal 2 aims for the end of hunger and malnutrition for all by 2030 – closing the gaps on food fortification is essential to the success of this effort.

Photo credit: Greg S Garrett, GAIN