1. Reviewing the Potential and Limitations of Food Fortification as A Component of Public Health Nutrition Omar Dary, Ph.D. A 2 Z/The USAID Micronutrient and Child Blindness Project

2. OD-2006-16-FF-Review 2 Some Favorable Statements “Food fortification resolves many issues of equity and access because it is population based and the fortification of staple foods reaches those most vulnerable to nutritional deficiencies.” “Food fortification is also cost-effective.” In: Benefit of Food Fortification. Food Fortification Approaches. www.sph.emory.edu/PAMM/IH552/Jan28fortification /

3. OD-2006-16-FF-Review 3 One More Optimistic Statement “Among the several proven approaches available for addressing the problem of micronutrient malnutrition, fortification is currently the most cost-effective and sustainable.” Jere H. Haas and Dennis D. Miller Symposium of food fortification in developing countries: J Nutr 2006;136:1053-1054.

4. OD-2006-16-FF-Review 4 Another Supporting Expression but with a Caution Note “We conclude that iron fortification is economically more attractive than iron supplementation.” “The results should be interpreted with caution, because evidence of intervention effectiveness predominantly relates to small-scale efficacy trials, which may not reflect the actual effect under expected conditions.” Rob Baltussen, Cécile Knai and Mona Sharan Iron fortification and supplementation are cost-effective. J Nutr 2004;134:2678-2684.

5. OD-2006-16-FF-Review 5 A Positive View but Keeping Attention to Other Interventions “Economic analysis suggests that fortification is indeed a very high-priority investment.” “Because supplementation is more costly than fortification, its recommended use depends on circumstances. ” Sue Horton Symposium of food fortification in developing countries: Economics of Food Fortification J Nutr 2006;136:1068-1071.

6. OD-2006-16-FF-Review 6 Cost of Supplying one EAR/day for the Whole Year to Women of Reproductive Age NutrientsUS$/yearNutrientUS$/year Calcium2.105Niacin, B-12~ 0.040 Iron 0.036 – 0.823 B-1, B-2, B-6~ 0.015 Vitamin A 0.023 - 1.060 Folate, Zinc~ 0.008 Vitamin C 0.242 Iodine 0.002 Considering loses during production, storage and distribution, and mineral bioavailability.

7. OD-2006-16-FF-Review 7 Alternatives to increase intake of micronutrients in populations Population Coverage Additional Intake and Bioefficacy Targeted FortificationMass Fortification Dietary Supplements as Home Fortification Dietary Supplements

8. OD-2006-16-FF-Review 8 Cost of Fortificants Relative to the Cost of Production (%) * It considers only the fortification process. 80-90 10-40 ~ 10 < 1.0 What about the distribution costs?

9. OD-2006-16-FF-Review 9 Annual estimated cost (US$) of several micronutrient interventions Conclusion: Mass fortification has the lowest cost if production and distribution are assured.

10. OD-2006-16-FF-Review 10 Mass-FF has a Low Cost if Production is Centralized (case: salt iodization program) Item * Medium 200 MT/day Small 20 MT/day Artisanal 1 MT/day #Factories 17140 Inspections per year (2, 4*, 12** at US$50/e.o.) US$ 100US$ 1,400*US$84,000** Analysis (2 per visit, at US$10/each) US$ 40US$ 560US$33,600 Auditing (10% visits) (US$500/visit) US$ 0US$ 1,500US$84,000 Yearly TotalUS$ 140US$ 3,460US$ 201,600 % Fortificant Cost § 0.5 %11.5 %672.0 % !!! § Assuming US$0.003/year per person and 10 million persons.

11. OD-2006-16-FF-Review 11 But Centralization is insufficient: Why Sugar Fortification Became a Program and MSG did not? Food Consumption (g/day) Additional Intake (µg ER/day) Impact Retinol (µmol/L) Sugar20 - 100337 0.72  1.06 MSG0.24 – 0.40336 0.67  0.92 * To supply 300  g ER/day. ** Adjusted to prices in 2006. Food [Vit. A] (mg/kg) Cost per person (US$/year)* % Price of Food ** Sugar150.0702.3 % MSG800 - 20000.08620.0 % Project of MSG collapsed a few years after introduction, and never became a program.

12. OD-2006-16-FF-Review 12 Comparisons of Several Potential Vehicles VehicleNutrient (% EAR) Amount Fortificant (g/MT) DilutionVeh. Price Fortificant Cost as % Price Vehicle/ Fortificant (US$/kg) SaltIodine (100%)7513,333$0.200.9 % Salt Iodine (100)+ Fe(60)+Vit.A (35) 5,980167$0.2043.6 % Bouillon Cubes (US$0.01/4 g) Iodine (100)+ Fe(60)+ Vit.A (35) 5,980167$2.503.2 % “Sprinkles“ (US$0.02/5 g) Multiple, (80-100%) 17,54457$4.0010.0 % Conclusion: Addition of vitamin A and/or Iron to salt would work only in very unusual conditions (high subsides, special factories, e.g.). Thus, it may be preferable to place attention to other alternatives. How much nutrients can be added to bouillon cubes?

13. OD-2006-16-FF-Review 13 FF effectiveness mainly depends on the consumed amount of the fortified food (case of refined wheat flour)

14. OD-2006-16-FF-Review 14 CountryFood Micronutrient (mg/kg) Food Consumption (g/day) % EAR 1 WorldwideSalt Iodine (20 – 40) 5 – 10210 % Central America Sugar Vit. A (5 – 20) 60-120 (30-60) 2 210 % Chile Wheat Flour Folic Acid (1 – 4) 200212 % Viet NamFish Sauce Iron-NaFeEDTA (1000) 1071 % 1. EAR for reproductive-age women 2. Consumption of preschool-age children. Examples of Efficacious* Mass-FF Programs * Efficacious  Successful

15. OD-2006-16-FF-Review 15 Effectiveness Evaluation of the Sugar Fortification Program in Guatemala (1975-76) Per capita intake (µg/day) VITAMIN A INTAKE MILK RETINOL (< 20 µg/dL) SERUM RETINOL (< 20 µg/dL) Source: Arroyave et al. 1979.

16. OD-2006-16-FF-Review 16 EVOLUTION OF NUTRITIONAL BLINDNESS IN CHILDREN OF GUATEMALA 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 Source: National Committee for Blind and Deaf of Guatemala Start of sugar fortification with vitamin A

17. OD-2006-16-FF-Review 17 FF Assessments Should also Include Intake Measurement Theoretical Case of Fortification with Vitamin A in the ECSA Countries Could the additional intake be a criterion of success? - Proportion of the population (at least 30%) receiving at least 20% EAR? - Proportion of the population moved from below to above the EAR? Who will estimate these and other parameters?

18. OD-2006-16-FF-Review 18 Complementary Measures should be wisely combined Complementation Partial Impact Emphasizing only one food or one social group

19. OD-2006-16-FF-Review 19 Technical conditions that determine feasibility of mass fortification 1.Truly industrial and centralized production. 2.Low price increase due to fortification. 3.Large dilution factor (> 1:2,000). 4.No segregation (solid or liquid). 5.Adequate nutrient stability. 6.No negative changes in the sensory properties of the food.

20. OD-2006-16-FF-Review 20 Conclusions 1.Mass fortification is cost-effective only for a proportion of the target population. In most circumstance, several interventions must be adequately combined to reach the nutritional goal. 2.If the objective is to provide additional amounts of micronutrients, dietary supplementation seems to be an adequate alternative (weekly?) when mass fortification has limitations. 3.Targeted fortification is part of the good manufacturing practices in the production of foods for special groups.