Addressing micronutrient deficiency in food based safety nets:

Is fortification the answer?

Patrick Webb

Dean for Academic AffairsFriedman School of Nutrition Science and Policy

Tufts University

Oct 2, 2008

The effects of Rising Food Prices on Poverty in MexicoJorge Valero-Gil and Magali Valero (Sept 2008)

After considering the positive effects of public policiesannounced in 2008, such as reduced taxes and tariffs on food products and greater subsidies to the extremely poor, the extreme poverty rate measured through consumptionincreases from 10.6% to 16%.

Policies oriented towards relieving the food price pressure on the Mexican poor should aim at lowering the prices of eggs, vegetable oil, milk, and chicken.

Source: Fries (2005)

Disease Nutrient Location Year(s) Deficiency (Group affected)

Scurvy Vitamin C Sudan 1984, 1991 Kenya 1994/95Afghanistan 2000-2002

Beri Beri Thiamin Mauritania 1974Thailand 1985

X.Thalmia Vitamin A Sudan 1984-1987

Pellagra Niacin Malawi 1989-1995Angola 2002-2005

-.5-.2

50

.25

.5

Jan96 Jul96 Jan97 Jul97 crisis Jan98 Jul98 Jan99 Jul99 Jan00 Jul00 Jan01Date

Chan

ge in

Z-S

core

Rel

ativ

e to

Base

Per

iod

Conditional Time Path of Child WAZ

Conclusion: No rise in child malnutrition?

Source: Block, Kiess, Webb et. al. 2004

-1-.7

5-.5

-.25

0.2

5.5

Jul96 Jan97 Jul97 crisis Jan98 Jul98 Jan99 Jul99 Jan00 Jul00 Jan01Date

Cha

nge

Rel

ativ

e to

Bas

e Pe

riod

(g/d

L)

95% confidence intervals

Conditional Time Path of Child Hemoglobin Concentration

In fact: Mean child Hb fell from 11.0 to 10.45Iron-deficiency anemia rose from 52% to 70%

Source: Block, Kiess, Webb et. al. 2004

Impact of currency devaluation in Senegal and Congo. Fouéré et. al. 2000. Public Health Nutr.

Depletion of fat and vegetable content of meals; cutting one daily meal.

Impact of maize price hike in Zambia: Gitau et. al. 2005. Public Health Nutr.

Decreased maternal plasma vitamin A during pregnancy (P = 0.028)and vitamin E postpartum (P = 0.042); no significant effects on maternal weight or infant weight.

Top emergency Food/Fuelfood aid recipients priority lists*

2007 2008

Ethiopia LiberiaSudan BurundiN. Korea EthiopiaUganda HaitiOPT MozambiqueKenya NigerAfghanistan Sierra LeoneZimbabwe ZambiaSomalia TajikistanDR Congo Burkina Faso

*Sources: FFP; HLTF; WHO; UNICEF; FAP; IFAD; WFP

Food/Fuel Anemia Vit. A def. Iodine def.priority lists* (<5s %) (<6s %) (∑ goiter rate)

Liberia 69 38 18Burundi 82 44 42Ethiopia 85 30 23Haiti 66 32 12Mozambique 80 26 17Niger 57 41 20Sierra Leone 86 47 16Zambia 63 66 25Tajikistan 45 18 28Burkina Faso 83 46 29

*Sources: FFP; HLTF; WHO; UNICEF; FAP; IFAD; WFP

Hyman (2004)

Nigeria

Populationaffected bydeficiencies

More

Less

More Severity of deficiencies Less

Retail processed

foods

Populationaffected bydeficiencies

Staple foodfortification

Supplementation

RUTFsHome

fortificants

Targeted supplementary

foodfortification??

FortifiedFood aid

More Severity of deficiencies Less

More

Less

Staple foodfortification

Nigeria has mandated the fortification of three staple foods with vitamin A: vegetable oil, wheat and maize flours.

South Africa has started fortifying flour and other foods.

Cote d’Ivoire, Morocco, Yemen and Bangladesh were among the first countries to start voluntary fortification of veg. oil with vitamin A

National oil fortification programs have now also started in Mali and Burkina Faso as well.

Vit. ASupplementation

Source: UNICEF 2007

170 mg maxSodium

76 μg*Iodine

47 μg*Selenium

3 mg*Copper

20 mg*Zinc

0.35 mg maxIron

73 mg*Magnesium

1173 mg*Potassium

0.1 mgBiotin

10 mg*Niacin

RUTFs

Homefortificants

Fortified Flours 10%

Fortified Blended Foods 6%

Cereals 73%

Pulses 7%Misc 1% Fortified Oil 4% Fortified Misc 0.36%

FortifiedFood aid

0.018.325.7Wild Foods0.024.043.5Vegetables0.613.516.1Fruits

65.36.295.1Oil46.26.992.2Sugar

0.03.44.4Eggs0.016.737.5Milk0.360.268.2Meat

65.729.164.6Pulses78.698.999.7Cereals

Source was food aid?*(%)

At least 3 days?(%)

At all(%)Foods/Groups

Consumed

Darfur 2006(N=2,090)

Frequency and Source of Foods Consumed

Source: Coates et. al (June 2007)

Food aid

Afghanistan: Wheat flour fortification

Staple foodfortification

2004: 37% <5s and 25% mothers anaemic

16 small-scale chakki mills used for start-up

Manual mixer needed to ‘dilute’ premix

Afghanistan: Constraints

While 70% accepted, 30% did not.Preference for imported white flour. No commercial incentive for millers.Assessed output capacity never reached.

Staple foodfortification

Conclusions:

1. Small-scale fortification = intensive, sustained interaction with many producers.

2. Quality control limited, but key to acceptability3. Acceptability requires social marketing

Southern Africa 2002/03: Maize meal

Crisis affecting 15 millions peopleGMO ‘crisis’ (related to trade rather than health)HIV prevalence

Opportunity fortify, since milling alreadyAgreements with 5 large roller mills in regionc. 150,000 MT meal fortified and distributed

Staple food/food aid

fortification

Southern Africa: successes

Kept mills openMillers willing to take husk to sell (animal feed market)Costs subsidized (premix, bagging, spare parts)Reasons well-understood (HIV rationale; GMO)Situation desperate (no alternative sources)

Staple foodfortification

North Korea: Fortified Blended Foods

6 million people on food aid3 million children (6m to 16y)300,000 pregnant/lactating mothers

Targeted supplementary

foodfortification

1998 national nutrition survey showed:62% stunting16% wastingVitamin A deficiency and anemia levels serious

Targeted supplementary

foodfortification

Primary and Boarding schools, Kindergartens

Fortified Biscuits

Pregnant and nursing womenFortified Noodles

Nurseries, Baby Homes, Children Centres, Pregnant and nursing women

Corn Soy Milk Blend (CSM)

Nurseries, Baby homes, Children Centres, Pregnant and nursing women

Cereal Milk Blend (CMB)

Baby homes, Children Centres, Paediatric hospitals/wards

Rice Milk Blend (RMB)

BeneficiariesCommodity

North Korea:

Power supply!Poor maintenance of unfamiliar technology/partsLimited milling capacity (to supply key input to FBFs)Uneven supply of inputs (for blended products)Lack transportation for finished products

But HUGE success60,000 MT FBF output by 2004 Dramatic improvements in nutrition 1998-2004

ChallengesChallenges

No coherence among fortification activities (Aceh)Some household resistance (Kabul) Some national resistance (Lebanon) – laws, politicsField-friendly assessment tools lackingIndustrial capacity/technology often limited

Costs not insignificant:Cash required…not just foodUnrestricted resources (earmarking)Local purchases of food (contracts, quality)Millers’ profits not assured without demandCosts higher when problem not universal

Addressing micronutrient deficiency in food based safety nets: Is fortification the answer?

No, its not ‘the’ answer

But it can be a partial response of real value:

Engaging dialogue on nutrition (hidden, long-term effects)Demonstrating public-private engagementBuilds national capacity, not merely ‘consumption’ response

Yes, worth supporting in some countries, for some commodities, as basis for long-term strategy—typically as part of a package of interventions.