Addressing micronutrient deficiency in food based safety nets: Is fortification the answer? Patrick Webb Dean for Academic Affairs Friedman School of Nutrition Science and Policy Tufts University Oct 2, 2008
The effects of Rising Food Prices on Poverty in Mexico Jorge Valero-Gil and Magali Valero (Sept 2008) After considering the positive effects of public policies announced in 2008, such as reduced taxes and tariffs on food products and greater subsidies to the extremely poor, the extreme poverty rate measured through consumption increases 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 1994/95 Afghanistan 2000-2002 Beri Beri Thiamin Mauritania 1974 Thailand 1985 X.Thalmia Vitamin A Sudan 1984-1987 Pellagra Niacin Malawi 1989-1995 Angola 2002-2005
Conditional Time Path of Child WAZ Change in Z-Score Relative to Base Period -.5 -.25 0.25.5 Conclusion: No rise in child malnutrition? Jan96 Jul96 Jan97 Jul97 crisis Jan98 Jul98 Jan99 Jul99 Jan00 Jul00 Jan01 Date Source: Block, Kiess, Webb et. al. 2004
Conditional Time Path of Child Hemoglobin Concentration Change Relative to Base Period (g/dl) -1 -.75 -.5 -.25 0.25.5 In fact: Mean child Hb fell from 11.0 to 10.45 Iron-deficiency anemia rose from 52% to 70% Jul96 Jan97 Jul97 crisis Jan98 Jul98 Jan99 Jul99 Jan00 Jul00 Jan01 Date 95% confidence intervals 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 aid recipients Food/Fuel priority lists* 2007 2008 Ethiopia Liberia Sudan Burundi N. Korea Ethiopia Uganda Haiti OPT Mozambique Kenya Niger Afghanistan Sierra Leone Zimbabwe Zambia Somalia Tajikistan DR 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 18 Burundi 82 44 42 Ethiopia 85 30 23 Haiti 66 32 12 Mozambique 80 26 17 Niger 57 41 20 Sierra Leone 86 47 16 Zambia 63 66 25 Tajikistan 45 18 28 Burkina Faso 83 46 29 *Sources: FFP; HLTF; WHO; UNICEF; FAP; IFAD; WFP
Hyman (2004) Nigeria
More Population affected by deficiencies Less More Severity of deficiencies Less
More Population affected by deficiencies Less RUTFs Fortified Food aid Targeted supplementary food Staple food fortification?? fortification Supplementation Retail processed Home foods fortificants More Severity of deficiencies Less
Staple food fortification 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. A Supplementation Source: UNICEF 2007
Home fortificants RUTFs Niacin Biotin Potassium Magnesium Iron Zinc Copper Selenium Iodine Sodium 10 mg* 0.1 mg 1173 mg* 73 mg* 0.35 mg max 20 mg* 3 mg* 47 μg* 76 μg* 170 mg max
Cereals 73% Fortified Food aid Fortified Flours Pulses 7% 10% Misc 1% Fortified Oil 4% Fortified Misc 0.36% Fortified Blended Foods 6%
Source: Coates et. al (June 2007) Frequency and Source of Foods Consumed Food aid Darfur 2006 (N=2,090) Foods/Groups Consumed At all (%) At least 3 days? (%) Source was food aid?* (%) Cereals 99.7 98.9 78.6 Pulses 64.6 29.1 65.7 Meat 68.2 60.2 0.3 Milk 37.5 16.7 0.0 Eggs 4.4 3.4 0.0 Sugar 92.2 6.9 46.2 Oil 95.1 6.2 65.3 Fruits 16.1 13.5 0.6 Vegetables 43.5 24.0 0.0 Wild Foods 25.7 18.3 0.0
Afghanistan: Wheat flour fortification Staple food fortification 2004: 37% <5s and 25% mothers anaemic 16 small-scale chakki mills used for start-up Manual mixer needed to dilute premix
Afghanistan: Constraints Staple food fortification While 70% accepted, 30% did not. Preference for imported white flour. No commercial incentive for millers. Assessed output capacity never reached. Conclusions: 1. Small-scale fortification = intensive, sustained interaction with many producers. 2. Quality control limited, but key to acceptability 3. Acceptability requires social marketing
Southern Africa 2002/03: Maize meal Staple food/ food aid fortification Crisis affecting 15 millions people GMO crisis (related to trade rather than health) HIV prevalence Opportunity fortify, since milling already Agreements with 5 large roller mills in region c. 150,000 MT meal fortified and distributed
Southern Africa: successes Staple food fortification Kept mills open Millers 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)
North Korea: Fortified Blended Foods Targeted supplementary food fortification 6 million people on food aid 3 million children (6m to 16y) 300,000 pregnant/lactating mothers 1998 national nutrition survey showed: 62% stunting 16% wasting Vitamin A deficiency and anemia levels serious
Targeted supplementary food fortification Commodity Rice Milk Blend (RMB) Cereal Milk Blend (CMB) Corn Soy Milk Blend (CSM) Fortified Noodles Fortified Biscuits Beneficiaries Baby homes, Children Centres, Paediatric hospitals/wards Nurseries, Baby homes, Children Centres, Pregnant and nursing women Nurseries, Baby Homes, Children Centres, Pregnant and nursing women Pregnant and nursing women Primary and Boarding schools, Kindergartens
North Korea: Power supply! Poor maintenance of unfamiliar technology/parts Limited milling capacity (to supply key input to FBFs) Uneven supply of inputs (for blended products) Lack transportation for finished products But HUGE success 60,000 MT FBF output by 2004 Dramatic improvements in nutrition 1998-2004
Challenges No coherence among fortification activities (Aceh) Some household resistance (Kabul) Some national resistance (Lebanon) laws, politics Field-friendly assessment tools lacking Industrial capacity/technology often limited Costs not insignificant: Cash required not just food Unrestricted resources (earmarking) Local purchases of food (contracts, quality) Millers profits not assured without demand Costs 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 engagement Builds 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.