USAID's chief nutritionist discusses West Africa's food fortification success

Just over 20 years ago, surveyors fanned out across the eight member countries of the West African Economic and Monetary Union (French acronym UEMOA). Their mission: assess the food consumption patterns of women and children in thousands of villages, towns, and informal settlements across the region.

Their research formed the basis of the most ambitious food fortification program on the African continent. The surveyors identified a handful of processed foods that women and children ate no matter where they lived and no matter their budget. The list of foods, which included cooking oil, wheat flour, sugar, and bouillon cubes, became the foundation for a regional food fortification program.

Food fortification aims to address the most common form of malnutrition – deficiencies in essential vitamins and minerals known as micronutrients. These deficiencies, especially in the vital nutrients of vitamin A, iron, folic acid, and other B vitamins, elevate risk for of child and maternal mortality, child blindness, birth defects, and cognitive impairment.

Researchers estimated that 54 percent preschool-age children in UEMOA, which has a population of about 95 million, were vitamin A deficient, and 13 percent of pregnant women had night blindness. The region had one of the highest rates of under-five mortality in the world, with one-third of childhood deaths attributed to undernutrition.

The effort later expanded to include the entire Economic Community of West African States (ECOWAS). Today, 12 of 15 ECOWAS countries mandate the fortification of all domestically produced cooking oil and 14 out of 15 mandate the fortification of domestically processed wheat flour. An estimated 84 percent of the roughly 350 million people in ECOWAS countries have access to micronutrient-fortified wheat flour, and 74 percent have access to vitamin A-fortified vegetable oil. Researchers estimate that fortifying cooking oil alone prevents 14,500 child deaths each year.

The program demonstrates how fortification can serve as a nutritional safety net and also how health leaders can leverage economic unions and organizations such as ECOWAS and UEMOA to further health gains.

Researchers have found that “several countries that would benefit from LSFF [large scale food fortification] have not yet incorporated this strategy within nutrition-related policy or programming. As a first step, countries should consider legislation of fortified grains, oil, and other staples where vulnerable populations exist and consumption of these staple foods is high.”

Exemplar News spoke with USAID Chief Nutritionist Shawn Baker about why food fortification programs are particularly important today, and what health leaders can learn from ECOWAS' success.

Why is ECOWAS’ food fortification program so relevant today?

Baker: We know that low-income households spend an inordinate amount of their budget on food. Any shock to supplies can increase food prices and that automatically pushes poor households into food insecurity. What we find is that poor households respond to shocks by deprioritizing meat, dairy, fruit and vegetable intake, and their diets become more limited to staples that can fill bellies. This creates huge risk for micronutrient deficiencies.

Today, Russia’s invasion of Ukraine is disrupting supplies of wheat, sunflower oil, and fertilizer. Russia and Ukraine account for 30 percent of global wheat exports. This has global repercussions and can increase food insecurity, making fortification more relevant than ever. Fortification acts like a micronutrient security blanket because it relies on universal staples and condiments that are on everyone’s plate to deliver critical nutrition. That’s why fortification should be considered a fundamental building block for food systems.

And there is every indication that fortification is going to grow in importance, not only because the impacts Russia’s invasion of Ukraine is having on the global food supply. But also because of climate change, which is creating extreme weather events that are reducing harvests. Ongoing urbanization also increases the potential impact of food fortification programs, because fewer people are growing their own food and more people are consuming processed foods. These trends position fortification as an increasingly powerful tool.

That said, fortification doesn’t solve everything. And it doesn’t solve the problem of ensuring a diverse diet for everyone. Efforts to ensure a diverse and healthy diet for everyone need to continue. In the meantime, fortification can be an important lever that is especially powerful during shocks.

Fortifying foods is also amazingly inexpensive. It is truly an incremental cost, that’s why most food processing companies readily embrace food fortification programs when they understand the major impact as compared to the minor costs. USAID estimates that for every dollar invested into salt iodization there is a USD $30 return on investment. USAID also estimates that country-wide fortification programs can save national economies an estimated 2 to 3 percent of GDP.

How resistant to participating in food fortification programs were local and national food processors in West Africa?

Baker: To answer this question, it helps to understand a few common misperceptions about food fortification. First, there was a misperception that fortifiable foods would not reach at-risk populations. A second misperception was that the West Africa food processors would resist joining such efforts, or that they would not have the capacity to maintain the necessary standards. A third was that fortification programs served as a market grab by multinational food processors.

None of these proved to be true. The food consumption surveys demonstrated the potential reach of fortifiable foods. Most of the national food processing companies have aligned with world-class standards. When you make the case that fortification is global best practice, they are eager to come on board.

Also, these companies are part of the social fabric of their country. They understand the risks and want to be a part of the solution. They have worked with regulators to follow the standards. The data demonstrates this. Today, an estimated 70 percent of all the cooking oil consumed in this region continues to be locally manufactured and processed, and is fortified with vitamin A.

It is important to note that fortification requires public-private partnership. For example, Benin, Burkina Faso, Côte d’Ivoire, Guinea Bissau, Mali, Niger, Senegal, and Togo established national alliances for food fortification. These alliances generally meet quarterly and provide an important forum for national-level discussions, coordination, strategic thinking, and oversight of food fortification. Participants include the ministries of health, commerce and industry, finance, and communications; agencies responsible for food regulation; United Nations agencies, including UNICEF, World Food Program, WHO, and the Food and Agriculture Organization; nongovernmental organizations; research institutions; industries; food importers; consumer associations; and the media.

How common are fortification programs around the world today?

Baker: Currently, 140 countries have national salt iodization programs, 86 countries fortify at least one type of grain, and 40 countries fortify oils, ghee, or margarine.

EOWAS includes Benin, Burkina Faso, Cape Verde, Cote D’Ivoire, The Gambia, Ghana, Guinea, Guinea Bissau, Liberia, Mali, Niger, Nigeria, Senegal, Sierra Leone, and Togo. More recently, Cameroon, Tanzania, and Mozambique have joined the ECOWAS effort to fortify cooking oil. All ECOWAS countries mandate fortification of salt with iodine, including the salt used in bouillon cubes. All ECOWAS countries except for Cape Verde and The Gambia have mandatory fortification of cooking oil with Vitamin A, and all ECOWAS countries except The Gambia have mandatory fortification of wheat flour with iron and vitamin B9. Nigeria mandates the fortification of sugar and maize flour with vitamin A, and Liberia mandates the fortification of sugar with vitamin A. Research is currently underway assessing the efficacy of fortifying bouillon cubes with other nutrients, including iodine, iron, zinc, vitamin A, folic acid, and vitamin B-12 in Burkina Faso, Ghana, Senegal, and Nigeria. Bouillon is widely used in cooking in West Africa.

Does fortifying foods increase consumption of foods that aren’t healthy because those foods are labeled as containing special nutrients?

Baker: Because fortification programs are generally accompanied by communications programs that inform consumers of the benefits of fortified products, there was some concern that the fortification program in Nigeria, which fortifies sugar, or ECOWAS’ fortifying salt, would push up consumption of sugar and salt.

But fortification marketing programs don’t try to increase consumption of a particular product. Instead, they try to shift consumption of a particular product like sugar or salt from an unfortified brand to a fortified brand. There is no evidence from ECOWAS, Nigeria, or one of the world's longest standing fortification programs, in Guatemala, that fortifying foods like sugar or salt increases consumption.

Given growing food insecurity, driven by climate change and conflict, how might countries or regions accelerate efforts to fortify foods?

Baker: We know that establishing a fortification system takes time because these programs must be based on a detailed understanding of consumption patterns and industry capacity. But there are four ways to accelerate and optimize these programs.

First, where they exist already, national decision makers should examine any performance gap between the standards mandated by law and the current fortification levels observed. Second, as consumption patterns shift, we need to shift the design of existing programs. Fortification programs need to be regularly assessed and updated. Third, leaders should be looking for new opportunities to fortify foods. A good example of this is ECOWAS’ research on fortifying bouillon cubes. This hadn’t been done before and is a response to the opportunity to reach large numbers of households. Lastly, health authorities should consider what additional nutrients they might add to the fortification efforts of existing foods. For example, iodine is added to salt all over the world. In countries engaging in salt fortification, they may want to ask, 'What else can we add to salt? Perhaps folic acid?' Despite the success of fortifying cereal flours with folic acid, we continue to lose around 170,000 infants' lives each year, because their mothers had inadequate levels of folate. Looking beyond cereal flours can increase the reach of folic acid fortification.