Reviewing the Potential and Reviewing the Potential and Limitations of Food Limitations of Food Fortification as A Fortification as A Component of Component of Public Health Nutrition Public Health Nutrition Omar Dary Omar Dary , Ph.D. , Ph.D. A A 2 2 Z Z /The USAID Micronutrient /The USAID Micronutrient and Child Blindness Project and Child Blindness Project
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Reviewing the Potential and Limitations of Food Fortification as A Component of Public Health Nutrition Omar Dary, Ph.D. A 2 Z/The USAID Micronutrient.
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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
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
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.