Food Fortification Initiative spotlights lack of regulatory compliance as obstacle to progress

30 Apr 2024 --- Operating in at least 30 countries worldwide, the Food Fortification Initiative (FFI) supports countries to build vital fortification programs that reduce micronutrient deficiencies. FFI and its partners have recently seen significant improvements in people’s iron, folate and vitamin B12 status due to a wheat flour fortification program in Haryana, India, a state with the highest micronutrient deficiencies in the country.

Simultaneously, the organization believes more can be done worldwide to enforce food fortification regulatory practices in regions with existing fortification programs.

Nutrition Insight catches up with Jessie Genoway, communications director of FFI, who shares some of the most effective tools used by the organization to realize food fortification initiatives, its business strategy, successes and challenges.

“It depends on the context, but I would say one challenge we see most commonly in countries where they might already have a fortification program set up is a lack of regulatory enforcement from the government and a lack of compliance from industry to the country’s fortification standards,” Genoway explains.

“That’s a big deal because, for people to receive food that’s fortified with the type and level of nutrients that their country standards outline, the program must be regulated, and the food industry must comply. These standards are tailored to address the micronutrient deficiencies present in the country and are ideally in line with scientifically-backed WHO guidelines.”

As a result, when FFI works in a given country, it encourages the government to mandate fortification. Mandates should be backed with a budget to pay government regulators, set up a level playing field for the industry and help ensure food is adequately fortified.

Fortification mandates
FFI often sees food fortification not being carried out in places where it is voluntary. For example, in the US, where it is voluntary to fortify corn masa products, only a few companies do it. A recent study observed that only 5.8% of corn masa products in the US are fortified with folic acid.

“Often, the industry will not fortify if it’s not mandatory because it doesn’t make business sense to them. They would need to increase the price of the food they fortify to cover costs, potentially losing consumers and making fortified foods less accessible to the people who need them most,” Genoway notes.

“Countries need to have a mandate where all of the product is fortified so that the cost remains low for consumers. We find that those in the private sector are often strong champions for fortification — for a mandate specifically — as a way to strengthen public health.”Regulatory compliance around food fortification is a priority for FFI.

Specific regions that FFI is currently focused on include Africa, India, Southeast Asia, Eastern Europe and Central Asia. The organization supports state efforts to mandate corn masa fortification in the US. Wheat flour, maize flour and rice are all fortified in the US and are part of the national standards, but corn masa fortification is excluded.

This has created a gap because the Hispanic population in the US, who mainly consumes corn masa, is significant and growing. Genoway points out: “A lot of the US Hispanic population primarily consumes corn masa flour products, and they’re not getting the folic acid that most US citizens do through fortified wheat flour and rice, for example. The US Hispanic population also sees the highest rates of neural tube defects in babies, which can be caused by folate deficiency.”

Quashing micronutrient deficiencies
FFI has prioritized several states in India with a substantial burden of micronutrient deficiencies in iron, folate and vitamin B12. The organization works on a state-by-state basis rather than a national level because the autonomy of state governments and consumption patterns vary by region.

“The country’s wheat flour and rice milling industry is somewhat industrialized, and wheat flour and rice are also widely consumed. We see these staple foods as effective opportunities to transform nutrition in the country through several social protection programs that reach millions of people, particularly the most vulnerable to micronutrient malnutrition.”

“We’ve prioritized 18 states that are primarily wheat flour consuming. We are working in three right now with the support of the Rockefeller Foundation — Haryana, Maharashtra and Rajasthan state. We have been working in Haryana since 2014.”

The state is densely populated and has one of the highest percentages of anemic women and children in India, coupled with a high prevalence of neural tube defects like spina bifida. There are around 40 neural tube defects per 10,000 births.

“This is all with the backdrop that wheat flour is commonly consumed there, particularly as a type of wholemeal, stone ground wheat flour called atta. We worked with the government of Haryana and several other partners like the Postgraduate Institute for Medical Education and Research, Chandigarh, the US Centers for Disease Control and Prevention and the WHO to start providing fortified atta through their social protection programs,” says Genoway.

FFI supported the government to create regulatory guidelines, provided training and technical assistance to millers and helped partners monitor the program. 

Before the fortification program began, blood samples were taken from beneficiaries to determine which micronutrient deficiencies were present in the population. 

After three years, an end-line assessment was taken, and a significant reduction of micronutrient deficiencies was observed.The Pacific Islands Africa, India, Southeast Asia, Eastern Europe and Central Asia, Southern and Eastern Africa, Eastern Europe and Central Asia are focus areas for FFI’s current advocacy work. 

“It is particularly exciting to have this data because many Indian policymakers request India-specific evidence before they start a fortification program. We’re taking the evidence of the health impact in Haryana and sharing it with other state governments interested in wheat flour fortification. The scientific evidence has generated a lot of momentum,” says Genoway. 

The national fortification standards in India are up to 13 times lower than WHO guidelines and will likely not reduce micronutrient deficiencies. In Haryana, FFI and its partners observed positive reductions in micronutrient deficiencies in those who received atta fortified in line with WHO guidelines. FFI is currently working to advocate for the Indian government to adopt fortification standards following WHO guidelines. 

Genoway notes: “It’s important that countries create standards that align with WHO guidelines and fit a country’s nutritional needs. Those guidelines have been developed using expert input, scientific data and years of evidence that fortification is safe and effective.”

Guiding methodology
FFI provides various phases of technical support for public, private and civic stakeholders, such as finding champions to advocate for and carry the work forward or mapping the regional context by collecting and analyzing data to create practical steps toward food fortification. 

“One thing we’ve seen working well is to have national food fortification alliances created in-country where public, private and civic stakeholders all meet in the same room periodically, talk about concerns, work on ways to improve fortification and just make sure that everybody’s on the same page,” says Genoway.

“These groups have been an important, effective mechanism that we’ve seen help improve challenges like low compliance and regulation.”

Part of the FFI’s strategic plan involves scaling up cereal grain fortification programs in a few target regions. The organization has developed proposals for supporting fortification efforts in the Pacific Islands, other Indian states, parts of Africa, Eastern Europe and different geographies.

Genoway comments that many countries express their interest in fortification as a strategy to help them reach their Sustainable Development Goals or commitments made as part of the 76th World Health Assembly Resolution on Food Fortification. Fortification can also help countries build nutrition resilience in the face of climate change and food insecurity.

“Many countries are very close but need help either with going the last mile and creating mandatory fortification legislation or to have support with strengthening government regulation and industry compliance,” she says.

“Our vision is that there’s a world where everybody has access to healthy, micronutrient-rich foods, where fortification programs are properly regulated, industry is complying and fortification is having a tremendously positive health impact on the population. We work for a world where micronutrient malnutrition does not exist, where women aren’t faced with conditions like severe anemia that doubles their risk of death during or shortly after pregnancy and where children get the nutrients they need to grow and thrive.”

Another health challenge FFI seeks to prevent through fortification is the incidence of neural tube defects caused by folate deficiency, such as spina bifida. About 75% of children born with the congenital disability die before their fifth birthday. “We see a world where children aren’t faced with those odds. We hope that comes sooner rather than later, and we’ll continue working tirelessly to support countries and their fortification journeys,” Genoway concludes. 

By Inga de Jong