Fortifying staple foodstuffs

Vitamin A, iron, folate and iodine deficiency disorders are the primary micronutrient deficiencies of public health concern. Vitamin A is critical for preventing childhood blindness and protecting the immune system, iron helps prevent anaemia and folic acid can prevent neural tube birth defects. Severe iodine deficiency during pregnancy detrimentally affects maternal thyroid function and child neurobehavioral development. 

These disorders are holding entire communities back – children don't develop fully, parents can't work efficiently, and too much money is spent on the medical treatment of nutrition-related health problems. The Global Alliance for Improved Nutrition (GAIN), created by the UN in 2002, is the only global organization with an exclusive focus on malnutrition. To date, GAIN has helped 811 million people, about 369 million of whom are women and children, to access affordable, nutritious food. 

Over the years we have developed a deep understanding of what it takes to tackle this complex problem and focused our mission on the delivery of innovative solutions to malnutrition that have a large-scale impact. One of them is food fortification.

What is food fortification?

Food fortification – the practice of adding small and safe amounts of micronutrients to staple foods and condiments – is a powerful nutrition success story that is reaching millions across the world. It is simple and among the world’s most cost-effective development interventions. 

The fortification of staples and condiments has been practiced in North America and Europe since the 1920s, and it has greatly contributed to the virtual eradication of pellagra, goitre, beriberi and scurvy. 

The World Bank and the Copenhagen Consensus(2)  ranked food fortification as one of the best investments in development in terms of cost effectiveness, since it improves people's health, while indirectly boosting productivity and economic progress.

Salt farms in the Philippines. © GAIN, alliance mondiale pour l’amélioration de la nutrition

The example of adding iodine to salt

Let’s take the case of “salt iodisation”. Iodine deficiency is one of the leading causes of preventable mental handicaps worldwide, and can lead to a reduction in IQ of 10-15 points.

The solution is quite simple and cheap: adding iodine to salt. Thanks to Universal Salt Iodisation (USI), which has been implemented around the world, the number of countries classified as “iodine deficient” decreased from 54 in 2003 to 32 in 2011(3).  

The implications of this for improved productivity are enormous. And it has all been done for relatively low levels of investment. The cost to iodise salt has been estimated at between USD 0.5-10 cents per person per year. For every dollar spent the resulting benefits, in terms of increased productivity and a reduction in spending on health care, are valued at more than USD 26.

Switzerland has been, and still is, considered a model country when it comes to the iodisation of edible salt. It started to add iodine to salt already in 1922, becoming the first country in Europe to introduce this kind of public health intervention(4).

Maps © GAIN

GAIN’s approach

Especially by developing large-scale food fortification programmes, GAIN has proved that multi-stakeholder partnerships – when governments, civil society and business work together – are the key to success. 

In particular, GAIN helps establish alliances for fortification that bring together governments, the private sector (including food companies and millers), civil society, international agencies and academia. Known as National Fortification Alliances, these groups enhance communication and collaboration, creating an enabling environment for support and advice on the process. GAIN also serves as a technical adviser to food industries, as well as a partner to governments to improve the quality and monitoring of fortified foods. 

Impact achieved 

Our work to fortify staple foods and condiments with essential micronutrients reaches more than 40 countries worldwide. GAIN-supported fortification programmes have helped to reduce: neural tube defects in South Africa through flour fortification with folate; iron deficiency anaemia in Nigeria, Jordan and Morocco through wheat flour fortification with iron; and iron deficiency anaemia in Kenya and China through iron fortified soy sauce. 

More recently, through the fortification of edible oils with vitamin A, there have been significant reductions in vitamin A deficiency in Indonesia, as well as a high contribution to intakes in iron from fortified baladi bread in Egypt. In India, GAIN-supported school nutrition programmes now reach approximately one million children with improved micronutrient intake through fortified hot meals.

With funding from the Bill & Melinda Gates Foundation, GAIN and UNICEF have partnered to support the reduction of iodine deficiency in 15 countries. Since 2009, this collaboration has been committed to reaching over 500 million people with adequately iodised salt through sustainable, business-led and market-orientated efforts.

GAIN has developed a series of tools that provide the basis for research to evaluate the contribution and effectiveness of large-scale food fortification programmes, such as the Fortification Assessment Coverage Toolkit (FACT). A survey carried out using FACT confirmed that the large-scale food fortification efforts in Senegal have made important progress in a relatively short period of time. They have improved the nutritional status of large parts of the population, including women of reproductive age, half of whom are considered at high risk of inadequate micronutrient intake. FACT showed that in Senegal there is a 60% coverage of poor populations with improved intakes of iron and vitamin A, demonstrating that fortification programmes can reach even the most vulnerable. 
These impressive results go some way to showing the health benefit of fortifying food with micronutrients. 

What’s next?

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 schoolchildren to learn better, prepares mothers for healthy pregnancies and prevents micronutrient deficiency diseases.

The challenge now is to achieve these results across the board. Otherwise, people will continue to be left behind. As the world population grows and rightly demands equitable development, there is the need to ensure that the poorest and most marginalised people can access more nutritious food. 

Greg S. Garrett, Beatrice Montesi