Why Fortify Foods?
Food systems often fail to sufficiently deliver foods rich in essential vitamins and minerals such as vitamin A, iron, iodine and folate. This failure is due to poor availability, access, affordability, and utilization of appropriate foods. The result is widespread micronutrient deficiencies and their negative health consequences which affect over 1.6 billion people around the world. The most vulnerable populations include women of reproductive age, young children, and female adolescents, particularly in low- and middle-income countries.
This micronutrient malnutrition – also known as “Hidden Hunger” – has significant health consequences. Preventable deficiencies in Vitamin A, D, iron, iodine, folic acid, and zinc contribute to up to three million child deaths annually. For example, iodine deficiency, is the world’s leading cause of preventable mental impairment. The economic consequences are also high. In low and middle-income countries alone, micronutrient deficiencies are estimated to cost an annual gross domestic product loss between two and five percent. Anaemia, for example, has been estimated to lead to 17 percent reduced lower productivity in heavy manual labour and an estimated 2.5 percent loss of earnings due to lower cognitive skills.
 McLean E, Cogswell M, Egli I, Wojdyla D, de Benoist B. Worldwide prevalence of anaemia, WHO Vitamin and Mineral Nutrition Information System, 1993-2005. Public Health Nutr 2009;12:444-54.
 Stein AJ, Qaim M. The human and economic cost of hidden hunger. Food Nutr Bull 2007;28:125-34.
 Horton S. The economics of food fortification. J Nutr 2006;136:1068-71.
Overview of Food Fortification
Food fortification is the practice of adding one or more essential nutrients to improve the nutritional quality of the food supply . The Food and Agriculture Organization (FAO) and the World Health Organization (WHO) identify food fortification as one of four main strategies for addressing micronutrient malnutrition. The others which complement fortification are supplementation, nutrition education, and disease control measures.
The appropriate aim of large-scale food fortification (LSFF) is to shift the distribution curve of intakes at the population level. This means that LSFF can reduce the number of people within the overall population who fall in the ‘deficit’ category. It can provide significant improvements in intakes among all population groups, but as a stand -alone intervention cannot eliminate deficiencies among all target groups.
LSFF can take several forms, including mandatory or voluntary fortification. Where national mandatory fortification programs have been implemented well and reached high coverage and quality, they have helped to significantly decrease micronutrient malnutrition among entire populations .
 European Commission Food Fortification Global Mapping Study. 2016. Accessed February 19, 2018. https://ec.europa.eu/europeaid/food-fortification-global-mapping-study-2016_en.
 World Health Organization, Food and Agricultural Organization of the United Nations. 2017. Guidelines on food fortification with micronutrients. Accessed February 18, 2018. http://www.who.int/nutrition/publications/micronutrients/9241594012/en/.
GAIN’s Legacy in Food Fortification
Since 2002, GAIN supported the roll out fortification in approximately 30 low and middle-income countries as an approach to help decrease malnutrition. This support helped to build, improve or sustain national LSFF programs. This investment in fortification has totalled a value of over USD 200 million made through grants and technical assistance. As a result of these efforts, 14 countries have now mandated LSFF, and an estimated one billion individuals have sustained access to fortified foods. For example, through GAIN’s program on salt iodization in over a dozen countries – which is a recommended program by GiveWell – some 470 million people have sustained access to adequately iodized salt. This includes 113 million children, from six months to 15 years of age.
In September 2015, GAIN and the Government of Tanzania co-hosted the first-ever Global Summit on Food Fortification. The event was co-convened by the African Union Commission, The Bill and Melinda Gates Foundation, Scaling Up Nutrition Secretariat, UNICEF, USAID and the World Food Programme. The Summit culminated in the Arusha Statement on Food Fortification calling for all fortification partners globally to undertake five actions: 1) generate new resources for fortification; 2) establish new programs; 3) improve compliance of existing programs; 4) fill research gaps; and 5) establish a global repository on fortification information.
 Knowles 2017, et al, Journal of Nutrition.
GAIN’s Approach to Food Fortification
Underpinning GAIN’s national-level project portfolio are its bespoke tools, global platforms and demand-driven service support. Fortification tools developed by GAIN in use by multistakeholders in over 20 countries include the Fortification Assessment Coverage Tool (FACT) and the Fortification Management Information System or FortifyMIS. Global platforms include:
- The ENABLE Platform – a technical hub offering audit, credit, procurement and capacity building services. ENABLE hosts the GAIN Premix Facility helping countries procure high quality, low cost premix thus filling a gap in the premix market;
- European Commission Fortification Advisory Services project;
- The Global Fortification Data Exchange; and
- hosting the Global Fortification Technical Advisory Group – a community of practice of over 20 international partners working in fortification.
At the country level, GAIN primarily supports mandatory fortification of commonly consumed food vehicles including salt, edible oils, wheat flour, maize flour, and rice. This is in line with the global evidence of impact. Further, following the recommendations of the Arusha Statement, our national-level technical support prioritizes building partnerships between the private sector, government as well as civil society (e.g. consumer protection agencies) and providing technical support so these actors can:
- expand fortification programs where there is a need and appropriate food vehicle;
- improve compliance of existing national programs; and
- monitor, measure and sustain more mature programs.
GAIN’s national support projects are active in Bangladesh, India, Haiti, Nigeria, Mozambique, Malawi, Tanzania, Pakistan, and Uganda.