The unfinished agenda for large-scale food fortification

Food fortification – the practice of adding small and safe amounts of vitamins and minerals to staple foods and condiments – is among the world’s most cost-effective development interventions and is helping to improve diets for millions across the world. Greg S. Garrett, GAIN’s Food Fortification Director, shares his views on what needs to be done to address the unfinished agenda on micronutrient malnutrition through food fortification. Additional contributions from Lawrence Haddad, GAIN’s Executive Director.

Tomorrow on the sidelines of the 70th World Health Assembly in Geneva, GAIN will be co-hosting an event on global iodine nutrition with WHO, ETH Zurich, Effective Altruism and the Iodine Global Network.

Fortifying salt with iodine prevents brain damage and irreversible reduction to the IQ of young children.  Iodizing salt has led us to the cusp of one of nutrition’s most exciting accomplishments – controlling iodine deficiency disorders at national levels around the world. Through a final push from donors and governments, the private sector, UNICEF, IGN, WHO and other partners — we can largely eliminate and control iodine deficiency disorders globally in the coming 5 years.  It’s within our grasp.  And beyond that, we have the potential to improve the health of hundreds of millions of people through fortifying flour and cooking oil with essential micronutrients.

Fortifying flour and other food staples with Iron and B12 protects against anemia, a major cause of maternal death and decreased productivity, and folic acid protects against neural tube defects like spina bifida, which can severely limit the quality of life for children and result in millions of dollars of additional health care costs. Adding zinc to wheat flour prevents diarrhea and infections and promotes growth. Fortifying cooking oil with vitamins A and D can help boost the immune system and protect against the effects of a number of diseases.

Today, over 140 countries implement national salt iodization programs (Figure 1), 86 countries mandate at least one kind of cereal grain fortification (Figure 2) and over 40 mandate the fortification of edible oils, margarine and ghee (Figure 3). While this is very compelling progress in terms of policy and legislation, how many more low- and middle-income countries could and should legislate fortification? What is the coverage and quality of delivery of existing programs? And can we show clearly that existing programs are having impact in these countries?

Figure 1- Legislation for salt iodization (Iodine Global Network, 2016)

Figure 2 – Legislation for the fortification of grains (wheat, maize and rice). (The Food Fortification Initiative, 2016), Figure 3 – Legislation for the fortification of edible oils, margarine and ghee (GAIN, 2016)

Legislation and standards

It is estimated that there are still 57 countries which do not have mandatory fortification of a cereal grain (e.g. maize flour, wheat flour and rice) with folic acid and iron. Yet these 57 appear to meet general criteria for establishing the intervention.[1] Of course, implementation research is required to ascertain if any of these countries consume ‘unfortifable’ grains, i.e. do not industrially mill their maize, wheat or rice.  In addition, consumption surveys would help build a critical understanding on the consumption of these food vehicles by vulnerable populations. Despite this, the available data indicate a very large unfinished agenda around the legislation of fortified grains with iron and folic acid. Similar conclusions can be drawn for the fortification of edible oils with vitamin A.  What’s more, many existing fortification standards appear to be sub-optimal requiring updates to align them with WHO recommendations.

Coverage and quality

Beyond that, we need to improve  coverage of currently mandated fortified foods. Effective data collection on coverage and evidence of impact by national governments or other actors is still scarce in least developed countries. Since 2014 GAIN has carried out  Fortification Assessment Coverage Tool (FACT) surveys in about a dozen countries, finding that  average coverage rates are not great, e.g. 35% of wheat flour consumed is fortifiable and yet only 18.5% is fortified. 72% consumed fortifiable edible oil but only 42% of this was fortified. For maize flour, 48% consumed and 29% fortified. Full data sets are available in this April 2017 Journal of Nutrition article.


On the quality side, international partners are working now to develop better guidance for quality and compliance monitoring. The limited data available indicate only 50% of samples tested adhere to national standards.[2] While this can come down to a range of factors such as standard variance and poor capacity to appropriately fortify and test foods for micronutrients, many samples labelled as fortified or not fortified at all. New global and national accountability measures are desperately needed to enhance the quality and compliance of national fortification programs, and to stamp out any fortification food fraud. GAIN believes that civil society and academia can help measure program performance more regularly through quality surveys, transparently providing results to all stakeholders including consumers..

Health impact monitoring

We know of there is strong evidence from developed countries that food fortification has been highly effective in addressing micronutrient deficiencies. But the evidence on health impact of food fortification in low and middle income countries — while growing and already clear for folic acid and iodine – is still scarce for the other nutrients such as iron. To build the evidence of program impact in these countries, GAIN commissioned a meta-analysis with the SickKids Center for Global Health in 2015. The results were presented at the Global Summit on Food Fortification (and available here), and should be published later this year.

So what does all this mean?

So while we’re celebrating the fact that we can largely eliminate iodine deficiency disorders in the next five years, there remains a very large unfinished agenda in terms of rolling out the other critical vitamins and minerals and food vehicles.  We need to continue to enact and enforce legislation improve coverage and quality of existing programs and to measure the impact of current efforts. And we need to do this now, because there are other exciting developments at our doorstep.  Biofortification is becoming a viable option to complement food fortification. Also, in July 2017, new, transparent data will be accessible to all through the launch of the Global Repository on Food Fortification.  And with the recent EC global mapping report on fortification, we are in an unprecedented position to be able to scale up this proven intervention appropriately so that it can make a much more significant impact on micronutrient malnutrition, and soon.

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Published 22 May 2017

[1] This figure has been calculated using: 2017 legislation data from the Food Fortification Initiative; available consumption data based on FAO food availability for rice, maize meal or wheat flour using WHO recommended cutoffs of  ≥75 g/c/d); and 2017 World Bank classifications for  low-, medium- and high-income countries.

[2] Luthringer CL, Rowe LA, Vossenaar M, Garrett GS. Regulatory monitoring of fortified foods: identifying barriers and good practices. Glob Health Sci Pract. 2015 09 02;3(3):446–61. pmid: 26374804