“Partnering with companies who have a long history of working in the food fortification space, can offer governments, NGOs and donors the support they need to select and successfully implement the best-suited fortification method and program, while also measuring results effectively. DSM has been promoting and actively engaging in staple food fortification for decades, providing its technical and scientific capabilities to its partners, as well as supplying them with high-quality, reliable and traceable micronutrient solutions. Together, the public and private sectors have the power to eliminate hidden hunger and achieve zero hunger by 2030 (SDG 2), creating a better and more sustainable future for all.”

Yannick Foing Global Lead Nutrition Improvement DSM

Hidden hunger, which refers to a lack of essential vitamins and minerals in ample or high-calorie diets, continues to be a major public health concern across both developing and developed countries. A form of malnutrition, it affects two billion people globally, with micronutrient deficiencies accounting for about 7.3% of the global disease burden.1 Hidden hunger can have devastating long term impacts on human health, including blindness, anemia, weakened immunity and inflammation that can contribute to cardiovascular disease (CVD).2,3,4,5,

Nutrition interventions, such as staple food fortification, can help combat hidden hunger on a global scale to grant more people access to affordable nutritious food, reduce healthcare costs and boost economic growth. Selecting and implementing the most effective and compliant solutions, however, can be a challenge for governments, non-governmental organizations (NGOs) and donors.

Improving public health with staple food fortification One of the most effective, safe and cost-efficient ways to tackle deficiencies in populations, fortification can enhance the nutritional value of staple foods by adding or replacing essential vitamins and minerals that may have been lost during processing. A long term investment for all stakeholders, staple food fortification can improve the health and wellbeing of individuals, and society as a whole. When fortification programs are successfully implemented, governments can quickly see tangible results — while millers can engage in socially responsible projects that will not only improve the health status of populations, but also, in turn, will see them benefit from consumers’ increased purchasing power, resulting from people’s increased capability to earn a living.

For fortification programs to be successful, it is crucial that regional and demographical preferences are considered when selecting the food vehicle. The selected food must be widely consumed by the target population to ensure nutrients can be delivered without altering existing dietary habits. Staple foods, such as flour and rice, are widely used for global fortification programs.

1. FLOUR More than 600 million metric tons of wheat and maize flour are milled annually and it is widely consumed in everyday foods, such as breads, biscuits, pasta and noodles.6 Both wheat and maize flour enjoy widespread consumer acceptance worldwide, but are particularly popular in Africa, the Middle East, South and South-East Asia and the Americas.7 Due to their versatility and availability, wheat and maize flour are considered highly suitable for fortification to deliver micronutrients to large consumer groups.

A significant proportion of the essential vitamins and minerals naturally available in wheat and maize are removed during the milling process. Replacing some of the micronutrients lost through milling is recognized as an effective way to improve the nutritional profile of flour — without affecting taste — and effectively combat hidden hunger. In countries where large numbers of individuals consistently do not consume sufficient quantities of specific vitamins and minerals, the World Health Organization (WHO) recommends not just replacing lost micronutrients, but also adding additional ones through fortification. Compulsory wheat and maize flour fortification is becoming increasingly common across the world; there are now 70 countries, including Canada, the US and UK, South Africa, Mexico and the Philippines, where it is mandatory to fortify at least one industrially milled cereal grain, such as maize or wheat.8,9

Depending on the fortification program, the cost that is passed to the consumer can be as little as USD$ 0.01 per 5 kg of flour, meaning that flour fortification is much less expensive than generally assumed. For millers, micronutrient premixes represent a cost-effective way to fortify flour. For example, a premix containing iron, folic acid and several B vitamins usually costs no more than USD$ 3 per metric ton of flour.10 Overall, the benefits of flour fortification significantly outweigh the investment required. Adding folic acid to the volume of flour consumed in the US each year could, for instance, prevent 767 live births with spina bifida.11 While the costs of fortifying this amount of flour total just over USD$ 4 million a year, this intervention saves around USD$ 607.3 million a year in healthcare costs.12 In this case, this represents a return on investment (ROI) of almost USD$ 152 per USD$ 1 spent.

2. RICE Rice is another staple food that can be found in many diets around the globe, including in Asia where individuals consume around 150 kg of milled rice annually. Although it is a great source of energy, processed (white) rice has a low overall nutritional value beyond carbohydrates and protein after milling. This is because the milling process removes the fat, as well as the more nutrient-rich bran layers. A wide variety of vitamins, minerals and other nutrients such as amino acids can be added to rice post-harvest through a range of fortification methods, such as dusting, coating or hot extrusion, to help fill the nutrient gap.

WHAT IS HOT EXTRUSION? Hot extrusion is considered the most robust method of rice fortification; broken rice grains are ground into rice flour, and mixed with water and the required nutrients to produce a dough. The fortified dough is then passed through an extruder to produce the fortified kernels, which are blended with regular rice, typically at a ratio of 0.5 to 2%. The temperature at which the extrusion takes place determines if we speak of hot or warm extrusion and has an influence on the rice starch gelatinization and thus firmness of the produced fortified kernels.

Rice fortified by hot extrusion enjoys widespread consumer acceptance, as it looks, cooks and tastes the same as its non-fortified counterpart — allowing it to be easily and seamlessly introduced into people’s diets. While the specific costs of fortified rice depend on several factors, such as the scale of the operation and the blending ratio of fortified to non-fortified kernels — rice fortification costs are small compared to the wide-reaching benefits. The cost impact is around 0.5 to 3%, yet such strategies could be a gamechanger for reducing malnutrition globally at both a population and individual level.

The World Health Organization recommends fortifying rice as a public health strategy with a range of micronutrients, including iron, folic acid and vitamin A.14 It is currently mandatory to fortify rice in a range of countries, including Costa Rica, Nicaragua, Panama, Papua New Guinea, Peru, the Philippines and some parts of the US.15

SUPPORTING BRIGHTER FUTURES Implementing staple food fortification programs has the potential to not only protect the most vulnerable populations, but also benefit societies as a whole. Beside national fortification programs, targeted nutrition interventions, such as school feeding programs and workforce nutrition programs, are also proving to be effective.

1. School feeding programs (SFPs) One way of reducing the risk of malnourishment or addressing existing malnutrition in children is through school feeding programs. Traditionally, SFPs have focused on children consuming enough calories and not going to school hungry. However, the importance of providing children with nutritious meals, which comprise nutrient-dense foods that are high in vitamins and minerals, is becoming increasingly recognized as an effective way to ensure these programs meet their objectives and are successful.

Hidden hunger can affect overall health and development, learning and cognitive function, as well as productivity and performance later in life. Local studies in Ethiopia, for example, indicate that 31% of school children are undernourished, out of which 19.6% are stunted, 15.9% are underweight and 14% are considered wasted.16,17 Further studies report that 47.4% of preschool-aged children and 25.4% of school-aged children suffer from anemia, or vitamin B12 deficiency, as a result of inadequate micronutrient intake.18 Anemia in children can contribute to a higher risk of disease and infection, poor cognitive development, impaired physical growth, poor school performance and work capacity, which, in turn, can limit social and economic development.19,20 Evidence suggests that SFPs that provide school-aged children with nourishing meals can promote micronutrient adequacy in their diets, leading to enhanced nutrition and health, and a better quality of life and wellbeing in adulthood.

2. Workforce nutrition programs Ensuring the world’s workforce has access to nutritious food, is crucial to allow individuals to perform at their fullest potential. Providing healthy and wholesome food choices for adults at work ensures people reach the recommended levels of essential micronutrients, reducing the risk of non-communicable diseases and sustaining energy levels to ensure their performance at full capacity. This can in turn reduce accident and absenteeism rates, thereby increasing productivity.

These programs are a compelling part of the solution to address hidden hunger and are important for business returns and economic growth. For instance, there are 350,000 workers in Singapore who are at risk of malnutrition.21 To deliver essential micronutrients to this target population through staple food fortification, DSM and BOP Hub — a Singapore-based business accelerator platform that aims to end poverty — launched the ‘45Rice’ project in 2016. Not only has the initiative been effective in combating hidden hunger, but a worker survey also showed that 90% of respondents approved of the fortified rice they were offered.

Taking the next steps While hidden hunger continues to be a major public health concern worldwide, staple food fortification in formats such as school feeding and workforce nutrition programs offers an effective, long term approach to addressing widespread micronutrient deficiencies on a global scale. It supports adequate nutrient intakes to promote the cognitive and physical development of children, as well as health and wellbeing of adults — leading to a better performance in school and at work.

This has the potential to lower unemployment and sick day rates, and reduce the pressure on healthcare systems globally.

Partnering with companies who have a long history of working in the food fortification space, can offer governments, NGOs and donors the support they need to select and successfully implement the best-suited fortification method and program, while also measuring results effectively. DSM has been promoting and actively engaging in staple food fortification for decades, providing its technical and scientific capabilities to its partners, as well as supplying them with high-quality, reliable and traceable micronutrient solutions. Together, the public and private sectors have the power to eliminate hidden hunger and achieve zero hunger by 2030 (SDG 2), creating a better and more sustainable future for all.

For further information on effective food fortification, visit www.nutritionimprovement.com or contact Yannick@Foing@dsm.com.

References: 1 World Health Organization, ‘The World Health Report 2002: reducing risks, promoting healthy life: overview.’, [report], 2002. 2 A. Sommer, ‘Vitamin A Deficiency and Its Consequences: A Field Guide to Detection and Control. Geneva’, World Health Organization, 1995. 3 Vitamin D council, ‘What is vitamin D?’, [website], 2011 https://www.vitamindcouncil.org/about-vitamin-d/what-is-vitamin-d/. 4 U.S. Institute of Medicine. ‘Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids’, [website], https://www. nap.edu/catalog/9810/dietary-reference-intakes-for-vitaminc-vitamin-e-selenium-and-carotenoids. 5 E. B. Rimm et al., ‘Antioxidants for vascular disease’, Med Clin North Am, 2000, vol. 84, issue 1, p. 239-249. 6 World Health Organization, ‘Recommendations on wheat and maize flour fortification. Meeting Report: Interim Consensus Statement.’, [report] https://www.who.int/nutrition/publications/ micronutrients/wheat_maize_fort.pdf. 7 Food Fortification Initiative, Country Profiles, www.ffinetwork.org/country_profiles/index.php, November 2018. 8 Food Fortification Initiative, Country Profiles, www.ffinetwork.org/country_profiles/index.php, November 2018. 9 Op. cit. (Food Fortification Initiative, Global Progress). 10 FFI Food Fortification Initiative. Accessed 11.2018 on www.ffinetwork.org/implement/toolkit.html. 11 Food Fortification Initiative (FFI).2017. Cost-effectiveness of Grain Fortification. http://ffinetwork.org/why_fortify/documents/Cost-effectiveness_2017.pdf. 12 Food Fortification Initiative (FFI).2017. Cost-effectiveness of Grain Fortification. http://ffinetwork.org/why_fortify/documents/Cost-effectiveness_2017.pdf. 13 World Health Organization, Fortification of Rice, [website],https://www.who.int/elena/titles/rice_fortification/en/, accessed March 2020. 14 World Health Organization, FORTIFICATION OF RICE WITH VITAMINS AND MINERALS AS A PUBLIC HEALTH STRATEGY,https://www.who.int/nutrition/publications/guidelines/rice-fortification-executive-summary.pdf?ua=1 15 Sight and Life, ‘Scaling Up Rice Fortification in Latin America and the Caribbean’, [website], 2017, https:// sightandlife.org/wp-content/uploads/2017/07/ScalingUp-Rice-Fortification-WFP-Rice-Fortification-ENG.pdf. 16 Degarege D, Degarege A, Animut A. Undernutrition and associated risk factors among school age children in Addis Ababa, Ethiopia. BMC Public Health. 2015;15:375. https://doi.org/10.1186/s12889-015-1714-5. 17 Wolde M, Birihan Y, Chala A. Determinants of underweight, stunting and wasting among schoolchildren. BMC Public Health. 2015;15:8. https://doi. org/10.1186/s12889-014-1337-2. 18 WHO, ‘Global anemia prevalence and number of individuals affected’, [website], https://www.who.int/vmnis/anaemia/prevalence/summary/anaemia_data_status_t2/en/ (accessed 25 April 2019). 19 Grantham-McGregor S, Ani C. A review of studies on the effect of iron deficiency on cognitive development in children. J Nutr. 2001;131(2):649–666. 20 Nokes C, van den Bosch C, Bundy DAP. The Effects of Iron Deficiency and Anemia on Mental and Motor Performance, Educational Achievement, and Behaviors in Children. An Annotated Bibliography. Washington, DC: INACG and ILSI Press; 1998. 21 YouTube, ‘Fortifying migrant workers in Singapore’, https://www.youtube.com/watch?v=kelrvGcFa5c&t=2s, accessed March 2020.