Despite positive developments in reducing malnutrition over the last few decades, hundreds of millions of people globally still do not consume adequate amounts of essential vitamins and minerals in their diets to sustain good health and development. This is referred to as “Hidden Hunger”, a major public health problem that is holding back entire communities.

1. T
hose suffering from Hidden Hunger
may not appear malnourished, but still
deal with the consequences of poor
brain development, immune function,
and work productivity. Especially
within the first 1,000 days “window
of opportunity” of a child’s life, from
conception to the age of two, a lack of
key micronutrients that contribute to
physical and cognitive growth can have drastic, irreversible, and
lifelong impacts.
Communities also suffer from reductions in economic growth
and a healthcare system overburdened by the medical treatment
of preventable nutrition-related health problems.
Food fortification: a proven, scalable, and cost-effective
nutrition intervention
Food fortification – the practice of adding small and safe
amounts of micronutrients to staple foods and condiments – is
a powerful nutrition success story that is reaching billions
across the world. It is simple, scalable and among the world’s
most cost-effective development
interventions.
The fortification of staples and
condiments has been practiced
in North America and Europe
since the 1920s, and it has
greatly contributed to the virtual
eradication of diseases like
pellagra, goitre, beriberi and
scurvy.
The World Bank and the Copenhagen Consensus ranked food
fortification as one of the most cost-effective development
investments, since it improves people’s health, while indirectly
boosting productivity and economic progress.
The example of flour fortification
The fortification of flour with multiple micronutrients, including
zinc, iron, and folate can help to alleviate the consequences of
Hidden Hunger of public health and economic concern.
Zinc helps strengthen the immune systems and lessens
complications from diarrhea, the number one killer of children
under five in low and middle income countries (directly
through dehydration and indirectly through preventing the
absorption of essential macro and micronutrients). Iron and
B-complex vitamins (especially B12) prevent nutritional anemia,
which improves productivity, maternal health, and cognitive
development. Folic acid reduces the risks of neural tube birth
defects (NTDs), a defect in the development of the spinal cord
that can lead to lifelong physical and cognitive disability.
The solution is quite simple and inexpensive: adding these
essential micronutrients to flour, one of the most widely
Alleviating
‘HiddenHunger’
whilstachievingadequateand
safefortificationby Corey Luthringer and
Beatrice Montesi, GAIN
Despite positive developments in reducing malnutrition
over the last few decades, hundreds of millions of people
globally still do not consume adequate amounts of
essential vitamins and minerals in their diets to sustain
good health and development. This is referred to as
“Hidden Hunger”, a major public health problem that is
holding back entire communities.
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2. consumed staple foods across all socio-
economic groups. The implications of
this for diseases prevention, improved
productivity and increased economic
potential are enormous and require
relatively low levels of investment.
If we look at the example of flour
fortification, it costs an estimated $US0.12
per person per year to fortify wheat flour
with iron and as little as US$0.06-0.24 per
person per year to fortify wheat flour with
zinc. These costs are minimal compared,
for example, to the cost of treating children
with spina bifida and immeasurable impact
on families.
It has been estimated that fortifying flour
with folic acid contributes to healthcare
savings of US$ 2.3 million in Chile, 40.6
million Rand in South Africa, and US$ 603
million in the US. Moreover, fortification
costs can easily be recovered through sales
of “value added” product in the markets.
Fortification is not only cost-effective, but also impactful.
Where flour fortification is mandatory, countries have
experienced between 31-58 percent reductions in NTDs. Global
NTDs prevalence is around 24 in 10,000 births, but typically it
drops to below 10 in 10,000 births after fortification with folic
acid.
The role of the private sector
The private sector, especially millers and producers who fortify,
are the gatekeepers to the nutritional health of the populations in
their distribution network. It is therefore critical for the private
sector to fully engage in the fortification process, and to ensure
that quality control and good manufacturing practices are in
place. This will allow households to consistently have access to
high quality, safe, and adequately fortified foods.
It is estimated that currently, in low and middle income
countries, less than 50 percent of products claimed as “fortified”
are adequately fortified to the levels indicated in their respective
national standards. These include countries where food
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3. fortification is mandatory by law and where businesses receive
support or incentives to fortify.
Enforcement and compliance need to be strengthened to ensure
the effectiveness of fortification programs, and there is a strong
need for the private sector to be the driving force for this change.
Food fortification should be seen as an opportunity for industry
to demonstrate corporate social responsibility and may at times
provide industry a competitive edge.
GAIN’s approach
The Global Alliance for Improved Nutrition (GAIN), one of the
few global organizations with an exclusive focus on malnutrition,
has developed a deep understanding of what it takes to tackle
this complex problem through food fortification, one of the main
nutrition interventions that has impact at scale.
Through developing large-scale food fortification programs,
GAIN supports countries to build, improve and sustain their
national fortification programs. GAIN has proven that multi-
stakeholder partnerships – when governments, civil society and
business work together – are critical to success. For example
National Fortification Alliances enhance communication and
collaboration, creating an enabling environment for support and
advice on the process.
GAIN’s work to fortify staple foods and condiments with
essential micronutrients reaches more than one billion people
in 40 countries worldwide. GAIN-supported flour fortification
programs have helped reduce neural tube defects in South Africa
through flour fortification with folate and iron deficiency anaemia
in Nigeria, Jordan and Morocco through flour fortification with
iron.
In 2010, GAIN and PATH launched a partnership project with
Urbano Rice to introduce affordable multiple-micronutrient
fortified rice in the Brazilian
market, while raising awareness
of the benefits of fortified
products.
Urbano, one of the leading
rice millers in Brazil
noted compelling business
opportunities in developing
a fortified product, including
competitive differentiation in
a flat growth market; brand-
building as an innovative and
socially conscious company; and
expansion of the product line
into export markets (e.g., Costa
Rica and Peru).
Urbano consequently
embraced fortification as part
of its marketing strategy, co-
investing substantially in store
collateral, tasting booths, and
other marketing materials to
promote the product.
Through innovative social
marketing, awareness of
fortified rice went from a very
low level to almost one third of
the exposed market in a span
of only 12 months. In terms of
sales, fortified rice has shown
consistent growth since its
introduction and faster consumer
uptake than comparable new rice subcategories in Brazil. Thanks
to the great support of Urbano, this project has reached an
estimated two million consumers.
More recently, GAIN, with the support of USAID, has launched
the Afghanistan, Pakistan and Central Asian Republics Regional
Fortification Initiative, which aims to build capacity for food
fortification in order to tackle micronutrient deficiencies across
the region, and in particular for Afghanistan.
The primary source of food energy intake in the region is
wheat flour. GAIN works primarily with Kazakhstan, the
world’s number one exporter of milled flour, to encourage
fortification prior to export to Afghanistan and other neighbors.
With the support of its partner agencies, GAIN also works to
harmonise import-export policies and fortification standards
within a regional initiative such as this, playing a role in
the trade environment to increase commerce and regional
connectivity.
Conclusion
While food fortification is not the only solution – dietary
diversity and affordable access to nutritious foods remain crucial
in the fight against malnutrition — it is a powerful tool that
enables schoolchildren to learn better, prepares mothers for
healthy pregnancies and prevents diseases that burden healthcare
systems. As the world population grows and urbanizes, the role
of industrially produced foods that can be fortified will continue
to increase.
The challenge now is to achieve adequate and safe fortification
across the board, otherwise people will continue to be left behind.
As the poorest and most marginalized people rightly demand
more equitable development, there is a need to ensure access and
affordability of more nutritious food across all communities.
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