Advances in food technology and

nutritional sciences
ISSN 2377-8350 [Link]
Open Journal

Special Edition
“Food Security and Food Sciences” Commentary: Food Fortification: African
Countries Can Make More Progress
Commentary
Corresponding author
* Andrew Method1* and Theodore H. Tulchinsky2,3
Andrew Method, MD, MPH
Amana Regional Referral Hospital
P. O. Box 25411
1
Amana Regional Referral Hospital, P. O. Box 25411, Dar es Salaam, Tanzania
Dar es Salaam, Tanzania Professor Emeritus: Braun School of Public Health and Community Medicine, Hebrew
2
Tel. +255 713 819081
University-Hadassah, Jerusalem 91220, Israel
E-mail: amethod1@[Link];
[Link]@[Link] 3
School of Health Professions, Ashkelon Academic College, Ashkelon 78108, Israel

Special Edition 1
Article Ref. #: 1000AFTNSOJSE1104
ABSTRACT

Micronutrient malnutrition (MNM) is a major public health issue in the developed

Article History
world, but it is even more important in low-income, developing countries. The main forms of
Received: August 21st, 2015
MNM include vitamin A, iron or iodine deficiency, but folic acid, vitamin D, selenium and zinc
Accepted: September 15th, 2015
deficiencies, although less recognized, are important as well. A lack of those micronutrients
Published: September 16th, 2015
represents a major threat to the health and development of populations, particularly children
and pregnant women. They account for 7.3 percent of the global burden of disease.
Citation
Method A, Tulchinsky TH. Com- In Sub-Saharan Africa where the prevalence of malaria, HIV, diarrhoea diseases and
mentary: Food fortification: African
other infectious conditions is high, MNM increases their severity and has a high health impact
countries can make more prog-
ress. Adv Food Technol Nutr Sci on children and pregnant women. In Africa, the prevalence of anaemia in pregnant women is
Open J. 2015; SE(1): S22-S28. doi: 52% percent and is a major factor that contributes to high maternal mortality rates. Vitamin D
10.17140/AFTNSOJ-SE-1-104 deficiency, rickets, osteomalacia and thyroid deficiency are highly prevalent chronic conditions
in low income developing countries.

For many years, food fortification has proven to be the most cost effective means to
prevent MNM. In recent years, many African countries have adopted mandatory fortification
schemes. In 2002, Nigeria successfully mandated a salt iodization program and the fortification
of maize and cooking oil with vitamin A, and sugar and flour with iron. The Tanzanian govern-
ment passed mandatory food fortification legislation in July 2011, and it provides a tax exemp-
tion for imported premix for its national fortification program. Such efforts by African coun-
tries are playing a vital role in addressing MNM in Africa. More effort and support are needed
to ensure that these programs are implemented successfully to effectively reduce MNM.

KEYWORDS: Food fortification; Micronutrient malnutrition (MNM); Folic acid; Vitamin D;

Vitamin B12; Deficiency.

ABBREVIATIONS: MNM: Micronutrient malnutrition; DALYs: Disability-adjusted life years;

VAD: Vitamin A Deficiency.

INTRODUCTION

Copyright This paper is written from the perspective of an African doctor with experience work-
©2015 Method A. This is an open ing in clinical and public health care and from that of a long experienced public health profes-
access article distributed under the sional. The following commentary is, thus, addressed to policy makers and international donors
Creative Commons Attribution 4.0 interested in advancing the health of the African population. In Africa, malnutrition affects all
International License (CC BY 4.0),
which permits unrestricted use,
age groups, but young children, women of reproductive age and the elderly tend to be among
distribution, and reproduction in those most at risk of developing micronutrient deficiencies. For decades, considerable effort
any medium, provided the original has been made to curb this “silent hunger”. In recent years, a number of African countries
work is properly cited. have initiated food fortification programs, which have proven to be cost effective in addressing

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 Advances in food technology and
nutritional sciences
ISSN 2377-8350 [Link]
Open Journal
the issue of food security. For example, in 2002, Nigeria suc- the US based on the country’s experience in combating pellagra.5
cessfully instituted a mandatory salt iodisation program, and it Niacin has been added to bread in the US since 1938, vitamin D
also began to fortify maize and cooking oil with vitamin A, and began to be added to margarine in Denmark in the early 1950’s,
sugar and flour with iron.1-3 This established it as one of the first and vitamins A and D were first added to Vanaspati (hydroge-
countries in Africa to embrace food fortification. A situational nated vegetable oil) in India in 1954.5 Folic acid is added to flour
analysis two decades later showed that regulatory monitoring is on a mandatory basis in over 60 countries to prevent neural tube
requisite to ensure that fortification reaches it maximum poten- birth defects.8
tial.4
The most widely used vehicles for fortification are
Micronutrient malnutrition (MNM) is widespread in among the most commonly consumed foods in Africa, includ-
industrialized nations, but more so in low income, developing ing oils and fats, milk, sugar, rice, wheat flour and maize flour,
regions of the world.5,6 Fortification is a means to increase the with all of these reaching the vast majority of the population.
content of essential micronutrients in basic foods; i.e., vitamins The micronutrients that must be fortified and consumed daily
and minerals (including trace elements), so as to improve the are vitamins and minerals, in the form of trace elements, which
nutritional quality of the food supply. Food fortification has ad- means that they required in only small quantities for growth and
vanced considerably in Africa,5 and along with providing needed development purposes (macronutrients are proteins, carbohy-
supplements to high risk groups, it provides public health ben- drates and fats).9 Food fortification is the most cost effective and
efits at a minimal cost and risk to the public.5 affordable way to reduce micronutrient deficiency in Africa.5

In Africa, the three most common forms of MNM are Types of Fortification
iron, vitamin A, and iodine deficiency but other forms of MNM,
including deficiencies of folic acid, vitamin D, selenium and Food fortification can take several forms. When we
zinc, are also important. Together, these affect at least one-third fortify foods that are widely consumed by the general popula-
of the world’s population, the majority of which resides in devel- tion, it is called mass fortification.9,10 To fortify foods designed
oping countries.5 MNM, being a risk factor for many diseases, for specific population subgroups, such as complementary foods
can contribute to high rates of morbidity and case fatality rates.5 for young children or rations for displaced populations, it is re-
It has been estimated that micronutrient deficiencies account for ferred to as targeted fortification; permitting food manufactur-
~7.3 percent of the global burden of disease, with iron and vita- ers to voluntarily fortify foods available in the market place, is
min A deficiency ranking among the fifteen leading causes of the termed market-driven fortification. An example of this type of
global disease burden.5 fortification is breakfast cereal, however, these cereals are not
commonly accessed by the low income majority that is most in
According to WHO mortality data, ~0.8 million deaths need of essential trace elements.9
(1.5 percent of the total) can be attributed to the annual level of
world iron deficiency, and a similar percentage of the world’s IMPORTANCE OF FOOD FORTIFICATION
vitamin A deficiency.5 In terms of the effect on overall health, as
expressed by the term “Disability-adjusted life years (DALYs)”, In 1981, Sir Nicholas Wald and colleagues at the Unit-
iron-deficiency anaemia results in 25 million DALYs lost (or 2.4 ed Kingdom’s Medical Research Council demonstrated in a ran-
percent of the global total), vitamin A deficiency in 18 million domized control trial that spina bifida and anencephaly (neural
DALYs lost (or 1.8 percent of the global total), and iodine tube defects) were folate deficiency disorders.8 Many years later,
deficiency in 2.5 million DALYs lost (or 0.2 percent of the global we are aware that folic acid fortification has proven to be a huge
total).5 In Africa, vitamin A deficiency significantly increases the success in preventing these conditions8 and that more than sixty
under-five years of age mortality and morbidity levels, while iron countries had started flour folic acid fortification programs by
deficiency anaemia is responsible for an estimated 20 percent of 2013.5 However, there is still resistance to mandatory fortifica-
all maternal mortality while also contributing to poor physical tion, and relatively few European countries have adopted this
and mental development in children.2 Such deficiencies increase practice, while all countries in the Americas and many others
the mortality rate from diseases such as measles, diarrhoea have done so. Birth defects are a major contributor to infant
diseases, malaria, tuberculosis, HIV/AIDS and others.7 mortality and morbidity, requiring costly life-long medical care.
The benefits of birth defect prevention through food fortification
Food fortification can lead to relatively rapid improve- are potentially large, and food fortification can be a very cost-
ment in the micronutrient status of a population, and at a very effective public health intervention.2
reasonable cost, especially if advantage is taken of existing tech-
nology and local distribution networks.5 This strategy has a long Fortification has nearly a century long record of suc-
historical background. Iodised Salt has been used in the United cess and safety, and it has proven effective in the prevention of
States since the 1920’s, and just prior to the US entering World specific diseases, including birth defects.5 Understanding the
War II, the fortification of milk with vitamin D, salt with iodine, pathophysiology and epidemiology of micronutrient deficien-
flour with iron, niacin and other B vitamins were entrenched in cies, and implementing successful methods of prevention, are

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 Advances in food technology and
nutritional sciences
ISSN 2377-8350 [Link]
Open Journal
both vital for nutritional security in setting contemporary public to agreed upon practices and to set standards for other voluntary
health standards for folic acid, vitamin A, vitamin B complex, fortification schemes. Recognizing that anti-fortification lob-
including vitamin B12,8 and vitamin D intake.11 If a food fortifi- byists and misinformation is widely distributed on the internet,
cation delivery system is in place, it is feasible to fortify it with well planned public information campaigns by the government
several micronutrients, making safe intervention relatively easy and NGOs will be required to lobby for improved maternal and
to implement, regulate and monitor. In this case, food fortifica- child health through fortification. Consumer acceptance is very
tion is a more cost effective and sustainable strategy than are important, and there should be no cultural objection to fortifica-
others.9 tion.3,9 The key players should ensure availability of micronutri-
ents in a sustainable way.5
Advantages of Food Fortification
Key Players
Food fortification has many benefits, since it utilizes
staple foods consumed by a large segment of the population, it The following key players needed to succeed in facili-
does not change the original product, it is technologically fea- tating a functioning and sustained fortification program include:
sible, and fortification can easily be implemented in developing government policy makers, the food industry, public health of-
countries.9 ficials, regulatory bodies, NGOs and international donors, and
quality monitors, such as nutrition bodies and community in-
Life styles have changed considerably around the volvement groups. Policy forums and community focus groups
world over the last several years. There is inadequate exposure can help to promote public understanding of the importance
to sunlight among children,12 primarily because children spend of fortification and to participate in reporting progress. Public
less time outdoors than they did in previous decades. The wide- health professionals and policymakers in state and local govern-
spread prevalence of vitamin D deficiency, even in sunny coun- ments, with the support of international agencies, have a moral
tries, is especially high among breast fed, dark skinned children responsibility to promote aggressive and well-supported nation-
and obese children and adults.13,14 Vitamin D deficiency is also al nutrition policies.3
widely prevalent in countries at low latitudes, where it was gen-
erally assumed that UV-B radiation was adequate enough to pre-
Criteria for Fortification
vent vitamin D deficiency, and in industrialized countries, where
vitamin D fortification of milk and margarine has been imple-
mented for many years.15 Supplements for pregnant women and An obvious requirement is that the fortified food(s)
infants, along with milk or other commonly used manufactured need to be consumed in adequate amounts by a large proportion
foods, fortified with vitamin D, are the most effective and af- of the target individuals in a population,16 and it should not ad-
fordable way to prevent vitamin D deficiencies, including rick- versely affect the balance of other nutrients.17 It is also necessary
ets and osteomalacia. Food fortification does not require people to have access to, and to use, fortifiers that are well absorbed
to alter their diet, thus, it is socially acceptable. The effect of for- yet do not affect the taste and appearance properties of foods. In
tification is rapid and covers a large part of the population with- most cases, it is preferable to use food vehicles that are centrally
out deleterious effects on taste, shelf life or the nutritional value processed, and to have the support of the food industry.5 Vehicles
of the food.5,9,16 Fortification is the most cost effective approach selected must be a part of the regular daily diet of the relevant
to prevent nutrient deficiencies.9,16 It can be introduced quickly segment of the population, the amount of nutrient added must
through existing marketing and distribution channels, and the provide an effective supplement for low consumers of the ve-
benefits are readily apparent.9 Apart from that, fortification will hicle, and it should not be harmful to the consumer or cause any
reach other high risk groups, such as the elderly. Through basic noticeable change in the taste, smell, appearance or consistency
food fortification, we may be able to prevent neuro-tube defects of the product.16
due to folic acid deficiency,17 Vitamin A deficiency (vitamin A),
rickets and osteomalacia (vitamin D),14 dental caries (fluorida- SUPPLEMENTATION
tion of drinking water in endemic areas), goitre and growth de-
lays (Iodization of salt)17 and ID anaemia (iron in salt or flour).9 Supplementation is another vital approach used to pro-
All these conditions can be prevented in the most at risk groups vide additional nutrients, as a key component of public health
of children and pregnant women.10,18 programs, such as maternal and child health. This requires a
long-term commitment and excellent outreach programs.17 Sup-
Requirements for a Successful Food Fortification Program plementation is the term used to describe the provision of in-
ternationally recognized doses of micronutrients, usually in the
In order to have a successful food fortification pro- form of pills, capsules or syrups.5 It has the advantage of being a
gram, political leadership and support from the health profes- viable means to supply an optimal amount of a specific nutrient
sions, industry and the general public are vital. Political will is or nutrients, in a highly absorbable form, and is often the fastest
needed to legislate mandatory food fortification and to regulate way to control deficiencies in individuals or population groups
the food industry, with adequate legislation to ensure adherence that have been identified as being deficient.5

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 Advances in food technology and
nutritional sciences
ISSN 2377-8350 [Link]
Open Journal
Fortification Technology sible.5 New low-cost tools are being developed to increase the
ease of assessing micronutrient levels in fortified foods, thereby
Fortification technology includes the dry mixing of improving program monitoring and effectiveness in an ongoing
foods, such as wheat and maize flour and their products, and and sustainable manner.2 More than 70 percent of the population
the supplementation of liquid and powdered milk, beverage of African countries with mandatory fortification and legislation
powders, breakfast cereals, cooking oils, rice and other widely is now estimated to be regularly consume at least one fortified
used processed foods.19 As well, nutrients can be dissolved or food staple daily.2,19 Zambia began a successful program of forti-
added in liquid milk, drinks, fruit juices, bread, pastas, cook- fying sugar with vitamin A in 1998. Continued support for food
ies, or sprayed on corn flakes and other processed foods that fortification is required to ensure scale-up throughout Africa.2 In
require cooking or extrusion steps that could destroy vitamin ac- South Africa, a significant decline in the prevalence of NTDs of
tivity. They can also be dissolved in oil for oily products, such as 30.5 percent was observed, from 1.41 to 0.98 per 1,000 births
margarine, or added for sugar fortification. Vitamin A in powder (RR 5 0.69; 95 percent CI: 0.49-0.98; p 5 .0379) following folic
form is absorbed onto the surface of sugar crystals when used acid fortification.22
with a vegetable oil or coated for foods like rice, where the vita-
mins sprayed over the grains must adhere to the food product to
avoid losses when the grains are washed before cooking.16

Monitoring Fortification for Quality and Impact

In order for fortification to have maximum health im-

pact, quality measures must be monitored routinely, with results
analyzed, and technical problems corrected.17 It is essential that
the process include food control and program monitoring.20
Food control can be internal (industrial), external (regulatory)
or commercial (households).20,21 Internal control is when public
or commercial flour millers use procedures such as recording
the use of premix and conducting spot tests to provide quality
checks, while external control is when government authorities Source: Flour Fortification Initiative.20
(such as food safety inspectors) test products at mills periodical- Figure 1: Countries (N=53) with regulations for fortification of wheat flour with folic acid, by
ly to ensure that fortification meets the country’s specifications. program status -worldwide, June 2010.

Commercial control is when food safety inspectors check retail

stores to be sure that the fortified product is in the marketplace.21 Case Report -Tanzania
Monitoring involves intake using household and market surveys
to confirm that fortified rice or food made with fortified flour In Tanzania, vitamin and mineral deficiency pose a se-
is purchased, that people are consuming it, and that enough is vere health problem, contributing to the heavy burden of disease
eaten to have the desired effect.20 Impact monitoring checks if and disability as well as exacting a heavy economic toll.23 In
products are fortified at recommended nutrient levels and at least April 1994, the national salt iodization program was official-
80 percent of the population is consuming the products, so that ly inaugurated, which led to the availability of iodized salt in
countries may assess the impact of biological and clinical out- households. Availability of iodized salt subsequently increased
comes.21 Measures such as child growth patterns, anaemia rates from nearly zero in the 1980’s to a sufficiency level of more
and iodine levels in the urine of pregnant women and schoolchil- than 90 percent.24 Total goitre prevalence decreased from 25 per-
dren are examples of vital biological monitoring. Data from rou- cent in the 1980’s to 7 percent in 2004. In addition, iodized oil
tine demographic and health surveys or birth defect surveillance capsules have been distributed to ~5 million persons 1-45 years
programs may be a valid indication of a fortification program’s of age in severely endemic areas. The WHO classifies Vitamin
impact.20 A Deficiency (VAD) in Tanzania as a clinical and public health
problem.25 Countrywide, an estimated 10,000 children are likely
CURRENT SITUATION to suffer from VAD-related blindness at any given time.7

Sub-Saharan Africa The success of Tanzania in improving food fortifica-

tion is partly due to improved community based programs with
Significant progress in food fortification is being strong community participation.7,26 But the government has also
achieved throughout Africa.2 In Sub-Saharan Africa, fortifica- been a contributing factor, with an announcement of mandatory
tion has become an increasingly attractive option in recent years, food-fortification legislation in July 2011, and enforcement be-
so much so that planned programs have moved forward to the ginning in May 2013. The government provides a tax exemption
implementation phase more rapidly than previously thought pos- for imported premix for the national fortification program.27

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Open Journal
CHALLENGES AND THE WAY FORWARD provide relevant nutritional information, particularly through
adequate labeling.35
Apart from these successes, food fortification faces a
number of challenges which must be addressed. Among these CONCLUSION
are the cost of fortification, a lack of dietary diversification, the
presence of natural anti-nutrient (i.e., phytates and tannins), Food fortification is vital to national, community and
disease and poor health due to AIDS, malaria and intestinal individual health, therefore, we should adopt guidelines and
parasites, low utilization rates in large mills and a general lack regulations to ensure its proper implementation, to use processes
of education.7 that cause minimal losses, and to choose packaging materials
that give maximum protection.16 Fortification by government
The benefits, safety and cost effectiveness of food mandate and regulation is essential, with cooperation from the
fortification have been demonstrated globally, hence, more effort private sector, food manufacturers, and in the context of broader
needs to be expended to ensure that all countries adopt mandatory policies for poverty reduction, education and agricultural re-
food fortification programs to reduce the burden of various form.1,34 It should be part of priority public health nutrition vital
diseases that especially effect children and pregnant women.28 To to the development of the nation, along with supplementation,
achieve this in Africa, a number of priority activities are required, for high risk groups and nutrition monitoring.
including harmonized fortification standards, strengthened
quality management systems and capacities, dedicated and CONFLICTS OF INTEREST
coordinated leadership and oversight of fortification programs,
fortification coverage assessments, fortification labelling, and The authors declare that they have no conflicts of interest.
continued advocacy and monitoring.2,29 Home fortification has
some advantages, and evidence in support of the efficacy of REFERENCES
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