“Life-saving vitamins and minerals should be made available through fortified grains to the billions around the globe who suffer from micronutrient deficiencies. This should be a rallying call to industries, to governments, donors, and other stakeholders. We must continue to enact and enforce fortification legislation and work together to boost quality and coverage of existing programmes and industry can self-regulate. We must measure and understand what works where and why.”

Greg S. Garrett Director, Food Policy & Finance Head of GAIN Switzerland Unfortunately, there may be more than two billion people still deficient micronutrients (vitamins and minerals). People need micronutrients to grow and be healthy. Vitamins and minerals are critical to better functioning immune systems, improved cognition and optimal growth and development.

One of the most cost-effective ways to ensure regular intakes of vitamins and minerals is via the fortification of commonly consumed staple foods. The incremental cost per person per year is low, at about $.12 for wheat and maize fortified with iron and folic acid. Globally, we have seen incredible scale up of the fortification of maize flour and wheat flour. Today over 80 countries fortifying these vehicles via mandates. The fortification of maize and wheat flour is literally reaching billions of individuals with improved intakes of micronutrients.

What has this led to? A new systematic review and meta-analysis of 50 studies the recent the impact of large-scale grain fortification programs in low- and middle-income countries (LMIC). These have helped achieve a 34% reduction in anemia from improved iron stores as well as a 41% decrease in the odds of neural tube defects due to reductions of folate deficiency among women of reproductive age. However, only 26% of wheat flour and 68% of maize flour, and less than 1% of rice milled in industrialized facilities is fortified. There are dozens of countries that could still mandate this intervention to improve health.

But even once a government has mandated wheat flour, maize flour or rice for fortification, that is a just a step. After legislation on paper comes legislation in practice: quality assurance and quality control, monitoring, incentives and deterrents to achieve compliance, and assessment of impact. For fortification to yield its intended impacts, high coverage of foods that are fortified in compliance with standards must be ensured and sustained. While data on the quality of fortified foods is limited, what exists delivers a cold splash of reality. It has been estimated that on average, only half of samples tested adhere to national standards (Luthringer et al., 2015). This is often driven by lack of capacity and willingness among industry and government.

When industry labels and markets under-fortified or unfortified foods as fortified, trust in food systems can erode. When governments fail to adequately monitor and enforce fortification and fail to build the capacity of food producers to fortify, industry is not motivated to comply. Either way, consumers lose.

New global and national accountability measures are needed to enhance quality and compliance of fortification programmes, and to stamp out low quality products of foods which should be fortified by law but which are not. Civil society has a role to play here in helping programme performance.

Measuring impact There is still a way to go to improve the quality of the evidence. Impact assessments should be built into well-designed and implemented fortification programmes to strengthen the evidence base for fortification. To this end, in 2013, GAIN developed the Fortification Assessment Coverage Toolkit (FACT) for assessing coverage of population-based and targeted fortification programmes (Friesen et al, 2017). Between 2013-2017, FACT surveys were conducted in 16 low- and middle-income countries . FACT survey results and other comparable survey data show disappointing household coverage and quality of fortified foods (Figure 1).

So how do we close the gap? Key elements of a national fortification delivery model are set out below. These build on the 2015 Arusha Statement on Food Fortification (Government of Tanzania, GAIN, 2015) and target new legislation, compliance with existing legislation, innovation to encourage solutions, and monitoring of progress through five key streams: 1. Advocacy to support to political processes, and capacity building to mandate new laws and expand national programmes. 2. Support to ensure adequate fortification standards and technical assistance to enable compliance with these standards. 3. Actions to improve monitoring, research and evaluation of programmes. 4. Hard and soft innovations to improve fortification quality and expand access to micronutrients. 5. Alignment of fortification and food safety programmes.

Adequate nutrition should not be a privilege in the 21st century. Food fortification is a dependable, low cost, sustainable approach to improving the nutrition of large numbers of people – it is not a luxury.

Life-saving vitamins and minerals should be made available through fortified grains to the billions around the globe who suffer from micronutrient deficiencies. This should be a rallying call to industries, to governments, donors, and other stakeholders. We must continue to enact and enforce fortification legislation and work together to boost quality and coverage of existing programmes and industry can self-regulate. We must measure and understand what works where and why.

Let’s get on with it and ensure more people have better access to the vitamins and minerals they need.

References Luthringer CL, Rowe LA, Vossenaar M, Garrett GS, 2015. Regulatory monitoring of fortified foods: identifying barriers and good practices. Global Health: Science and Practice 09 02;3(3):446–61.

Friesen, VM, GJ Aaron, M Myatt, and LM Neufeld, 2017. Assessing Coverage of Population-Based and Targeted Fortification Programs Using the Fortification Assessment Coverage Toolkit (FACT): Background, Toolkit Development, and Supplement Overview. Journal of Nutrition 147 (Suppl): 981S-3S.

The Government of Tanzania and the Global Alliance for Improved Nutrition (GAIN), 2015. The Arusha Statement on Food Fortification. https://www.gainhealth.org/wp-content/uploads/2015/05/Arusha-Statement.pdf