Reviewing the Potential and Reviewing the Potential and Limitations of Food Limitations of Food

Fortification as A Component Fortification as A Component of of

Public Health NutritionPublic Health Nutrition

Omar DaryOmar Dary, Ph.D., Ph.D. AA22ZZ/The USAID Micronutrient and /The USAID Micronutrient and

Child Blindness ProjectChild Blindness Project

OD-2006-16-FF-Review

2Some Favorable Some Favorable

StatementsStatements

“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/

OD-2006-16-FF-Review

3One More Optimistic One More Optimistic

StatementStatement

“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. MillerSymposium of food fortification in developing countries:

J Nutr 2006;136:1053-1054.

OD-2006-16-FF-Review

4

Another Supporting Another Supporting Expression but with a Expression but with a

Caution NoteCaution 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 SharanIron fortification and supplementation are cost-effective.

J Nutr 2004;134:2678-2684.

OD-2006-16-FF-Review

5

A Positive View but Keeping A Positive View but Keeping Attention to Other Attention to Other

InterventionsInterventions

“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 HortonSymposium of food fortification in developing countries: Economics of

Food FortificationJ Nutr 2006;136:1068-1071.

OD-2006-16-FF-Review

6Cost of Supplying one EAR/dayCost of Supplying one EAR/day for the Whole Year to Women of for the Whole Year to Women of

Reproductive AgeReproductive AgeNutrients US$/year Nutrient US$/year

Calcium 2.105Niacin, B-

12~ 0.040

Iron0.036 – 0.823

B-1, B-2, B-6

~ 0.015

Vitamin A0.023 - 1.060

Folate, Zinc ~ 0.008

Vitamin C0.242

Iodine0.002

Considering loses during production, storage and distribution, and mineral

bioavailability.

OD-2006-16-FF-Review

7 Alternatives to increase intake Alternatives to increase intake of micronutrients in populationsof micronutrients in populations

Population Coverage

Additional Intake and Bioefficacy

Targeted Fortification

Mass Fortification

Dietary Supplements as Home Fortification

Dietary Supplements

OD-2006-16-FF-Review

8

0

20

40

60

80

100

Mass* Fortification

Dietary Supp. TargetedFortification

Market-drivenFortification

% P

rice

Cost of Fortificants Relative to Cost of Fortificants Relative to the Cost of Production (%)the Cost of Production (%)

* It considers only the fortification process.

80-90

10-40

~ 10< 1.0

What about the distribution costs?

OD-2006-16-FF-Review

9

Annual estimated cost (US$) of Annual estimated cost (US$) of several micronutrient several micronutrient

interventionsinterventions Intervention

Cost of Micronutrients

Other Costs

Total for Product

Distribution Cost

Mass Fortification

1.50 0.25 1.75 Negligible

Targeted Fortification

1.50 13.50 15.00 + 365 days

Dietary Supplements

(daily) 1.00 6.00 7.00 + 365 days

Dietary Supplements

(weekly) 1.30 0.85 2.15 + 52 weeks

Conclusion: Mass fortification has the lowest cost if production and distribution are assured.

OD-2006-16-FF-Review

10Mass-FF has a Low Cost if Mass-FF has a Low Cost if Production is CentralizedProduction is Centralized

(case: salt iodization program)(case: salt iodization program)

Item *Medium

200 MT/daySmall

20 MT/dayArtisanal1 MT/day

#Factories 1 7 140

Inspections per year (2, 4*, 12** at US$50/e.o.)

US$ 100 US$ 1,400* US$84,000**

Analysis (2 per visit, at US$10/each)

US$ 40 US$ 560 US$33,600

Auditing (10% visits)(US$500/visit)

US$ 0 US$ 1,500 US$84,000

Yearly Total US$ 140 US$ 3,460 US$ 201,600

% Fortificant Cost§ 0.5 % 11.5 % 672.0 % !!!

§ Assuming US$0.003/year per person and 10 million persons.

OD-2006-16-FF-Review

11But Centralization is insufficient: But Centralization is insufficient: Why Sugar Fortification Became a Why Sugar Fortification Became a

Program and MSG did not?Program and MSG did not?

FoodConsumptio

n

(g/day)

Additional Intake

(µg ER/day)

ImpactRetinol

(µmol/L)

Sugar 20 - 100 337 0.72 1.06

MSG 0.24 – 0.40 336 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 **

Sugar 15 0.070 2.3 %

MSG 800 - 2000 0.086 20.0 %Project of MSG collapsed a few years after introduction, and

never became a program.

OD-2006-16-FF-Review

12Comparisons of Several Comparisons of Several Potential VehiclesPotential Vehicles

VehicleNutrient (%

EAR)

AmountFortificant

(g/MT)

Dilution Veh. Price FortificantCost as % PriceVehicle/

Fortificant(US$/kg)

Salt Iodine (100%) 75 13,333 $0.20 0.9 %

SaltIodine (100)+Fe(60)+Vit.A

(35)5,980 167 $0.20 43.6 %

Bouillon Cubes(US$0.01/4 g)

Iodine (100)+Fe(60)+ Vit.A

(35)5,980 167 $2.50 3.2 %

“Sprinkles“(US$0.02/5 g)

Multiple, (80-100%)

17,544 57 $4.00 10.0 %

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?

OD-2006-16-FF-Review

13

         

Adult Male - 320 g/day

0

50

100

150

200F

olat

e

Fe

B-1

2

B-1

B-2

B-6

Nia

cin

Zn

Vit.

A

Vit.

D

Nutrient

% E

AR

Adult Female - 160 g/day

0

50

100

150

200

Fol

ate

Fe

B-1

2

B-1

B-2

B-6

Nia

cin

Zn

Vit.

A

Vit.

D

Nutrient

% E

AR

4-6 y.o. child - 80 g/day

0

50

100

150

200

Fol

ate

Fe

B-1

2

B-1

B-2

B-6

Nia

cin

Zn

Vit.

A

Vit.

D

Nutrient

% E

AR

1-3 years old child - 40 g/day

0

50

100

150

200

Fol

ate

Fe

B-1

2

B-1

B-2

B-6

Nia

cin

Zn

Vit.

A

Vit.

D

Nutrient

% E

AR

FF effectiveness mainly depends on FF effectiveness mainly depends on the consumed amount of the the consumed amount of the

fortified food (case of refined wheat fortified food (case of refined wheat flour)flour)

OD-2006-16-FF-Review

14

Country FoodMicronutrient (mg/kg)

Food Consumpti

on(g/day)

% EAR1

Worldwide Salt Iodine(20 – 40)

5 – 10 210 %

Central America

Sugar Vit. A(5 – 20)

60-120(30-60)2

210 %

ChileWheat Flour

Folic Acid(1 – 4)

200 212 %

Viet NamFish

Sauce

Iron-NaFeEDTA

(1000)

10 71 %

1. EAR for reproductive-age women 2. Consumption of preschool-age children.

Examples of Examples of Efficacious* Mass-FF Efficacious* Mass-FF

ProgramsPrograms

* Efficacious Successful

OD-2006-16-FF-Review

15Effectiveness Evaluation of the Effectiveness Evaluation of the Sugar Fortification Program in Sugar Fortification Program in

Guatemala (1975-76)Guatemala (1975-76)

0

100

200

300

400

500

600

700

Basal II III IV V

SugarDiet

Per

cap

i ta in

take (

µg

/day) VITAMIN A INTAKEVITAMIN A INTAKE

0

10

20

30

40

50

Basal II I I I IV V

%

MILK RETINOLMILK RETINOL (< 20 µg/dL)(< 20 µg/dL)

0

5

10

15

20

25

Basal II III IV V

%

SERUM RETINOLSERUM RETINOL(< 20 (< 20 µg/dL)µg/dL)

Source: Arroyave et al. 1979.

OD-2006-16-FF-Review

16EVOLUTION OF NUTRITIONAL EVOLUTION OF NUTRITIONAL BLINDNESS IN CHILDREN OF BLINDNESS IN CHILDREN OF

GUATEMALAGUATEMALA

0

2

4

6

8

10

Year

Aff

ecte

d c

hildre

n in h

osp

ital

s of

Guat

emal

a an

d Q

uet

zalt

enan

go

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

OD-2006-16-FF-Review

17

FF Assessments Should also FF Assessments Should also Include Intake MeasurementInclude Intake Measurement

Proportion EAR From Several Foods

0

100

200

300

400

500

600

700

A B C

Consumer Consumption Patterns

% E

AR

M.FLOUR (1-70%)

W.FLOUR (10-80%)

OIL (50-80%)

SUGAR(10-80%)

Proportion UL From Several Foods

0

20

40

60

80

100

120

A B C

Consumer Consumption Patterns%

UL

M.FLOUR (1-70%)

W.FLOUR (10-80%)

OIL (50-80%)

SUGAR(10-80%)

Theoretical Case of Fortification with Theoretical Case of Fortification with Vitamin A in the ECSA CountriesVitamin 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?

OD-2006-16-FF-Review

18Complementary Measures Complementary Measures should be wisely combinedshould be wisely combined

Complementation

Partial Impact

Emphasizing only one food or one social

group

OD-2006-16-FF-Review

19Technical conditions that Technical conditions that

determine feasibility of mass determine feasibility of mass fortificationfortification

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.

OD-2006-16-FF-Review

20

ConclusionsConclusions

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.