Reviewing the Potential and Limitations of Food Fortification as A Component of Public Health Nutrit

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Reviewing the Potential and Limitations of Food
Fortification as A Component of Public Health
Nutrition

• Omar Dary, Ph.D.
• A2Z/The USAID Micronutrient and Child Blindness
  Project

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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/
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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
20061361053-1054.
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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 20041342678-2684.
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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 20061361068-1071.
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Cost of Supplying one EAR/day for the Whole Year
to Women of Reproductive Age
Considering loses during production, storage and
distribution, and mineral bioavailability.
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Alternatives to increase intake of
micronutrients in populations
Population Coverage
Additional Intake and Bioefficacy
Targeted Fortification
Mass Fortification
Dietary Supplements
Dietary Supplements as Home Fortification
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Cost of Fortificants Relative to the Cost of
Production ()
80-90
10-40
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lt 1.0
It considers only the fortification process.
What about the distribution costs?
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Annual estimated cost (US) of several
micronutrient interventions
Conclusion Mass fortification has the lowest
cost if production and distribution are assured.
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Mass-FF has a Low Cost if Production is
Centralized (case salt iodization program)
Assuming US0.003/year per person and 10
million persons.
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But Centralization is insufficient Why Sugar
Fortification Became a Program and MSG did not?
Project of MSG collapsed a few years after
introduction, and never became a program.
To supply 300 ?g ER/day. Adjusted to prices
in 2006.
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Comparisons of Several Potential Vehicles
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?
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FF effectiveness mainly depends on the consumed
amount of the fortified food (case of refined
wheat flour)
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Examples of Efficacious Mass-FF Programs
1. EAR for reproductive-age women 2. Consumption
of preschool-age children.
Efficacious ? Successful
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Effectiveness Evaluation of the Sugar
Fortification Program in Guatemala (1975-76)
Source Arroyave et al. 1979.
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EVOLUTION OF NUTRITIONAL BLINDNESS IN CHILDREN OF
GUATEMALA
Start of sugar fortification with vitamin A
1980 1982 1984 1986 1988
1990 1992 1994 1996
1998
Source National Committee for Blind and Deaf of
Guatemala
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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?

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Complementary Measures should be wisely combined
Complementation
Partial Impact
Emphasizing only one food or one social group
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Technical conditions that determine feasibility
of mass fortification

• Truly industrial and centralized production.
• Low price increase due to fortification.
• Large dilution factor (gt 12,000).
• No segregation (solid or liquid).
• Adequate nutrient stability.
• No negative changes in the sensory properties of
  the food.

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Conclusions

• 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.
• If the objective is to provide additional amounts
  of micronutrients, dietary supplementation seems
  to be an adequate alternative (weekly?) when mass
  fortification has limitations.
• Targeted fortification is part of the good
  manufacturing practices in the production of
  foods for special groups.