2023
Abstract: Large-scale food fortification (LSFF) has been recognized as one of the most cost-effective interventions to improve the intake of vitamins and minerals and decrease the burden of micronutrient deficiency. Indeed, the simple addition of micronutrients to staple foods, such as wheat, maize and rice, or condiments, including salt and bouillon, has tremendous potential to impact malnutrition. However, most LSFF programs have been poorly designed and have not taken into consideration critical inputs, including current levels of nutrient inadequacy and per capita consumption of different food vehicles when deciding which nutrients to add and at what concentrations. LSFF programs, like some other nutrition interventions, also tend to have low coverage and reach and lack monitoring to measure this and course correct. These program design flaws have resulted in limited effectiveness and have made it difficult to determine how best to harmonize LSFF with other interventions to reduce micronutrient deficiencies, including efforts to enhance dietary diversity, biofortification and supplementation. Furthermore, LSFF has often been touted as a population-based intervention, but in fact has heterogenous effects among sub-groups, particularly those with limited access to or inability to afford fortified foods, as well as those with higher physiological requirements, such as pregnant and lactating women. This article focuses on these limitations and the concerted efforts underway to improve the collection, analysis, and use of data to better plan LSFF programs, track implementation, and monitor coverage and impact. This includes a more sophisticated secondary analysis of existing data, innovations to increase the frequency of primary data collection and programmatically relevant visualizations of data of sub-national estimates. These improvements will enable better use of data to target resources and programmatic efforts to reach those who stand to benefit most from fortification.
- Introduction
Approximately 40% (3.1 billion people) of the world’s population is unable to afford a healthy diet [1]. A lack of access to healthy diets puts many of the most vulnerable populations at risk of micronutrient deficiency, which can cause an increased risk of disease and mortality [2] and new data showed high levels of deficiencies with half of the world’s young children and two-third of its women begin micronutrient deficient [3]. Unfortu-nately, micronutrient deficiencies often co-occur, especially in populations with low dietary diversity and inadequate access to micronutrient-rich foods and have a disproportionate impact on women and children [4,5].
Rather than making progress toward the 2030 Sustainable Development Goals in ending hunger and all forms of malnutrition, recent reports show that we are moving in the wrong direction on all nutrition targets (except exclusive breastfeeding). There is no shortage of evidence that the pandemic, climate change and conflicts have exacerbated the dire state of global food insecurity [1,6]. Significant changes are needed to improve food systems and diets, increase micronutrient intakes and put these goals back on track.
Large-scale food fortification (LSFF) is widely recognized as a cost-effective method to increase the micronutrient density within a food system [7]. Numerous staple food vehicles, including wheat, maize, and rice, as well as condiments and edible oils, have been fortified with micronutrients. Currently, the Global Fortification Data Exchange cites that 161 countries have mandatory or voluntary food fortification legislation for at least one food vehicle [8].
When well planned, LSFF has the potential to have a broad reach with significant improvements in health without extensive behavior change [9]. Two of the most notable LSFF success stories have been demonstrated through folic acid-fortified flours and iodized salt. The impact of folic acid fortification on neural tube defects is well documented, with reductions ranging from 15 to 58% in countries around the world [10,11]. For iodized salt, the Iodine Global Network estimates that 111 countries around the world now have adequate iodine intakes, and the prevalence of goiter is virtually eliminated [12]. Salt iodization has reduced the odds of goiter by 74%, according to a recent meta-analysis [9].
While these successes demonstrate that LSFF can have a significant impact on the health and well-being of a population, there are several factors related to design and moni-toring that hold it back from reaching its full potential. Data are needed to appropriately design and monitor LSFF programs to be as effective as possible at reducing the burden of micronutrient malnutrition [13–15]. This article will focus on the data gaps that are hampering LSFF programs and some potential solutions that are being developed to make sure that the target populations are being reached.