www.gainhealth.org

Assessing potential for parboil

rice fortification with zinc

Nutritious Rice Value Chain Project

2

•Micronutrient malnutrition results in an

estimated US$1 billion loss in economic

productivity in Bangladesh, annually1

•Zinc deficiency is the most prevalent

micronutrient deficiency in Bangladesh—

affects 45% of preschool-age children and

57% of women2

•Low dietary diversity is associated with

inadequate nutrient intakes in Bangladesh3

•Rice is widely consumed across the country.

Upwards of 70% of calories are derived from

milled rice (FAO, 2012).

0

10

20

30

40

50

60

70

Zinc - rural Zinc -urban

Vitamin A -rural

Vitamin A -urban

Preschoolchildren

Women(NPNL)

Rice provides 70% of energy

Source: FAO. Food security country profile, 2012.

16%

6%

2%

3%

70%

3% Other

Soybean oil

Wheat flour

Refined sugar

Palm oil

Milled rice

Bangladesh: Zinc deficiency and rice intakes

1FANTA Bangladesh PROFILES, 20122 ICDDR,B et al. National Micronutrients Status Survey, 2011-2012; 2013.3 Arsenault et al. J Nutr 143: 197-203; 2013.

3

ADDITION AND MITIGATION OF LOSSESZinc

Farm inputs

Production

Soaking/

Parboiling

Milling

Cooking

Zinc-fertilizer enriched rice

Fortify parboil soaking water with zinc

Nutrition-sensitive parboiling

Reduced milling

Zinc biofortified rice germplasm

Use

optimal

cooking

water

volume

Extrusion fortification

www.gainhealth.org

Nutrition

evidence

NUTRITION EVIDENCE + MARKET

POTENTIAL

Objective: Test interventions along the agricultural value chain to improve

the nutritional density of rice in Bangladesh.

SCALE

Inputs into Food Production

Food Production

Food Storage

and Home Processing

Industrial Food

Processing

Distribution Transport & Trade

Food Retailing, Marketing

& Promotion

Food Preparation & Catering

Farm Input Post-Harvest

Market

potential

5

ESTIMATED INCREASE IN RICE GRAIN

CONTENT (MG ZINC/ KG RICE) UPDATED

Source: GAIN Bangladesh Nutritious Rice Technical Assessment, 2013; Dalberg analysis.

0.9 – 1.3

Zinc fertilizer (foliar)

Zinc fertilizer (soil) 0.1 - 6.0

Parboiling optimization

11.7 – 11.8

2.4 - 4.0Reduced milling

Fortificant soaking

1.4 - 4.6

Range of values

6

SUMMARY OF MARKET ASSESSMENT FOR EACH OF

THE INTERVENTIONS CONSIDERED

Soil

Foliar

(0.1 to 6.0 μg/g)5

(1.4 to 4.6+ μg/g)5

(+0 to + 0.6 Tk)

(+1 to +1.5 Tk)

Reduced milling

Zinc fertilizer

Fortification during parboiling

Increase in zinc content

(zinc µg/g)1

Evidence of demand(price impact)2 Supply chain capacity

Regulatoryenvironment

(2.4 to 4.0 μg/g)4 (-0.3 to -0.6 Tk)

(+1 .5 to +1.8 Tk)

(6.0 to 23.4 μg/g)3

Nutrition-sensitive parboiling (0.9 to 1.3 μg/g)6

1

2

3

4

(price increase)

Positive rating Negative rating

Notes: (1) Increase in zinc content of milled, washed and cooked rice; (2) Demand assessment relies on multiple factors, impact on price is not the only dimension used for rating; (3) This is across all concentrations. (4) This is ranked lower because increased phytate levels in reduced milled rice decrease the ultimate nutritional impact of the concept; (5) Fertilizer values are based on literature review; for soil-based fertilizer, +0.1 μg/g of zinc is in zinc adequate soils, and +6.0 μg/g is in zinc deficient soils; for foliar fertilizer, the range is given for zinc adequate soils only; data does not exist forimpact on zinc deficient soils, but is likely to be higher than soil-based ones; (6) This figure is not statistically significant and the rating is therefore lowerSource: GAIN Bangladesh Nutritious Rice Technical Assessment, 2013; HarvestPlus; Interview with World Food Programme; Dalberg analysis

7

PARBOIL FORTIFICATION: ADDITION OF

SOLUBLE NUTRIENTS TO SOAKING WATER

BEFORE PARBOILING

• 1950-1960’s: Approach first used in Japan to increase amino acid content of

rice (lysine and thiamin)

• Brown or milled rice soaked in an amino acid solution

• Thiamin enrichment used at industrial level

• 2000’s: Prom-u-thai et all studies this process in depth for iron and zinc:

• 1.4x increase adding zinc at 50 mg/kg paddy (9.7 to 13.2 mg zinc/kg

milled rice)

• 4.5x increase adding zinc at 400 mg/kg paddy (9.7 to 44.1 mg zinc/kg

milled rice)

• Use of low pH and hot temperature in soaking water to boost uptake (of

iron)

• Did not conduct industrial pilot tests in Thailand: parboiled rice is for

export therefore not of national interest

8

ZINC CONTENT IN PARBOIL FORTIFIED RICE

11.0 12.213.5

15.917.112.6 16.4

19.6

23.3

28.2

32.9

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

0 100 150 200 300 500 700 900 1100 1300

Zin

c c

on

ten

t (m

g/k

g p

ad

dy d

ry w

t

Mg zinc / L or kg paddy

Cooked rice - low

Cooked rice - high

1.6x ↑

9

ZINC CONTENT IN PARBOIL FORTIFIED RICE

11.0 12.213.5

15.917.112.6 16.4

19.6

23.3

28.2

32.9

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

0 100 150 200 300 500 700 900 1100 1300

Zin

c c

on

ten

t (m

g/k

g p

ad

dy d

ry w

t

Mg zinc / L or kg paddy

Cooked rice - low

Cooked rice - high

1.6x ↑

This amount of zinc in the milled rice represents

only 2.2% of the zinc added to the system

10

ZINC RETENTION IN PARBOIL FORTIFIED RICE

AFTER WASHING AND COOKING

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

0 100 150 200 300 500 700 900 1100 1300

Zin

c r

ete

nti

on

%

Mg zinc / L or kg paddy

Retention (%)

11

IMPACT OF ZINC PARBOIL FORTIFIED RICE ON

THE PREVALENCE OF INADEQUATE ZINC

INTAKES

0

10

20

30

40

50

60

70

80

90

100

Baseline 15% 50% 80% Baseline 15% 50% 80%

300 mg zinc L-1

1300 mg zinc L-1

Children 2-3 yrs Women

Hotz et al. J Sci Food Agric. 95:379-85; 2015

12

EARLY RESULTS INDICATE THERE IS DEMAND FOR

NUTRITIOUS RICE

(1) The consumers were provided brief awareness / education via the survey question, which was: “If you were told that this rice (a) provided you and your family with vitamins (b) would help prevent diarrhea/other diseases for your family, particularly children; (c) made the children stronger, what would be the fair price for this rice?”Source: GAIN technical tests in labs (November 2013); Interviews with experts; GAIN Bangladesh Consumer Survey, 2013; Dalberg analysis

Control, open parboilFortified with 1300mg,

open parboil

There are limited changes expected

to the organoleptic properties of rice

Initial results indicate that there are limited

changes in the smell, texture or taste of the

rice either

Consumers are willing to pay a ~2

taka premium for nutritious rice

38.63 39.28 41.07

0

50

+0.65

Current rice

Nutritious rice, pre-awareness

Nutritious rice, post awareness1

Urban

(n=752)

35.65 36.16 37.53

0

20

40

+0.51

Overall

Rural

(n=498)

+2.44

+1.88

13

FORTIFICANT SOAKED RICE IS EXPECTED TO

BE 1-1.5TK/KG (~3-5% INCREASE) FALLING

WITHIN CONSUMER WILLINGNESS TO PAY.

Source: GAIN Miller Survey 2013; Interviews with millers; Dalberg analysis.

www.gainhealth.org 14

Industrial Pilot Study

Small Scale (0.4 MT)

500 and 1100 mg zinc/kg

paddy

www.gainhealth.org

INDUSTRIAL PILOT - SMALL SCALE

ENGELBERG MILL VS LABORATORY STUDY

0

5

10

15

20

25

30

35

40

Control 500 mg Zn/kg paddy

1100 mgZn/kg paddy

Engelberg study - 2015

1.5x ↑

1.9x ↑

15

0

5

10

15

20

25

30

35

40

Control 500 mg Zn/kg paddy

1100 mgZn/kg paddy

Laboratory study 2013

1.5x ↑

2.2x% ↑

MILLED RICE - RAW

www.gainhealth.org 16

0

200

400

600

800

1000

1200

1400

Husk Bran Byproducts (mixed)

By-products

Control 500 mg Zn 1100 mg Zn

↑ 11 x

↑ 14 x

Estimates (non-representative samples)

RESULTS: ENGELBERG MILL STUDY

Combined

sample

www.gainhealth.org

COST IMPLICATIONS FOR MILLERS

$US DOLLARS

Cost $US – based on 565 MT

annual production

500 mg/kg 1100 mg/kg

Supplies / equipment 650 650

Zinc sulfate 6 498 14 145

Subtotal / year 7 148 14 145

Additional cost/kg milled rice $US 0.012 0.026

Additional cost/kg milled rice

Taka

0.9 2.0

17

Within range of willingness-to-pay for ‘nutritious rice’ with health information

Up to 2.0 Tk premium

www.gainhealth.org

ENGELBERG MILL STUDY: BYPRODUCTS

Potential Risks

• Improper handling of byproducts

could create zinc contamination in

the environment

• Closed management system would

be required

• Husks are an important source of

fuel for rice mill boilers – if burned

would need to collect ash waste

18

Potential Opportunities

• Zinc may be extracted for use as

fertilizer – a clean, reliable, local

source

• If the zinc byproducts have monetary

value as fertilizer, millers would be

incentivized to sell

• Determine if zinc husks can be

burned for fuel, and the ash

recovered for use in fertilizer

ZINC IS CONCENTRATED IN BYPRODUCTS & EFFLUENT

www.gainhealth.org

ZINC SULFATE VALUE CHAIN

19

Steel

production

Zinc dust

recovery

Zinc sulfate

Micronutrient

Fertilizer

Animal Feed

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjjl6vTt53LAhXss4MKHZWEACEQjRwIBw&url=https://en.wikipedia.org/wiki/Zinc_sulfate&psig=AFQjCNH3cwYsMVGxWQoyVPQA4-VdK85q7A&ust=1456851164361661https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjjl6vTt53LAhXss4MKHZWEACEQjRwIBw&url=https://en.wikipedia.org/wiki/Zinc_sulfate&psig=AFQjCNH3cwYsMVGxWQoyVPQA4-VdK85q7A&ust=1456851164361661

www.gainhealth.org

ZINC FERTILIZER USE IN BANGLADESH

• Approximately half of arable land in Bangladesh is zinc deficient

• Use of zinc fertilizer for increased yield considered necessary by

government

• Usage of zinc fertilizer is low (~20% in 2012/13) compared to estimated

need

• No local manufacture of zinc fertilizer - imported (eg, China)

• Product adulteration is a problem – inadequate zinc, heavy metal

contamination

Increased use and quality of zinc fertilizers

20

www.gainhealth.org

SYSTEM REQUIREMENTS

Mills: Zinc fortification at

soaking

Zinc fortified milled rice

Zinc rich by-products &

effluent

Extraction / use in

fertilizer??

Rice production –

increase yield?

21

Food grade zinc sulfate

Consumers

$$

$$

$

X

www.gainhealth.org

CONCLUSIONS

• System was considered too

inefficient with too many

challenges/risks to invest further

• Other strategies - zinc biofortified

rice and extrusion technology

continue to be invested in

• These strategies are also

challenged by rice value chain

• Prevention of zinc deficiency –

need to look beyond rice as a

vehicle

22

Salt iodization: Successfully reaching billions

but suboptimal indicators

Omar Dary

USAID–Nutrition Division/HIDN/GH

USAID, Mini-University

March 4th, 2016

OD-2016-03

Fetus Abortion Stillborn Congenital abnormalities

Perinatal mortality

Infant mortality Neurologic cretinism: Mutism, mental retardation – deafness Endemic cretinism: dwarfism/ mental deficiency Psychomotor impairment

Infant Hypothyroidism / Irreversible mental retardation

Children and adolescent

IQ reduced / Goiter / Hypothyroidism / Impaired physical and mental development

Adult Goiter and complications Hypothyroidism

Consequences of iodine deficiency and excess

2424

Excesses

Temporal Permanent

Hyperthyroidism

(in population that were

iodine deficient)

Thyroid Cancer

(in adults from all sources of

iodine)

Brief history of iodized salt

YearAverage

[I] (mg/kg)Event

1915 SmallHunziker, in Switzerland, recommended adding small amount of iodine

to the diet of small children to prevent goiter.

1917 -Marine & Kimball (Akron, Ohio, USA) reduced goiter in girls using

supplements with iodine

1921 1.90 – 3.75 The salt iodization program started in Switzerland.

1924100.0

(average)

Michigan: Introduced, as prophylaxis against goiter, iodized salt; the

country (USA) has not accepted the practice as compulsory.

1962 7.5 Iodine content is increased in Switzerland.

1980 15.0 Nodular goiter raises temporally due to increment of iodine content.

1998 20.0 Another increment takes place based on epidemiological results.

2014 25.0 More recent increment in Switzerland to satisfy requirements for all.

Currently20-60

(range)Most countries, including USA; with common averages between 25

and 40 mg/kg.

25Source: Zimmermann oral communication and J Nutr 2008;138:2060.

26

Association between goiter and urinary iodine concentration*

Goiter %All Visible

UIC/E (µg/24 hours)*

Children 9-13 years in 9 localities

Nu

mb

er

of

cases

Source: Tobar E, Maisterrena JA, Chávez A. Iodine nutrition levels of school children in rural Mexico.

In: Stanbury JB, 1969. Endemic Goiter. PAHO, Sc. Publ. No. 193. pp 411- 415.

* The authors assumed that UIC was equivalent to 24-h UIE.

EAR = 73 µg/day

RNI (EAR) = 120µg/day

UL= 600 µg/day

27

Goiter prevalence vs urinary iodine in Central America – 1965-67

Source: Ascoli W, Arroyave G. Epidemiología del bocio endémico en Centro América. Arch Latinoamer Nutr 1970; 20:309-320.

* The authors estimated UIE based on UIC in causal urine samples adjusted by creatinine coefficient/ g creatinine x body weight

% g

oite

r p

reva

len

ce

UIE* (µg/day)

Design:

Around 30 localities per

country (186 in total);

3,181 urine samples

28

Goiter prevalence vs urinary iodine concentration for selecting indicator

Source: WHO Nutrition Unit. Indicators for Assessing for Control of Iodine Deficiency Disorders and their Control through Salt

Iodization, 1994, In: IOM, Academies of Science of the USA. Dietary Reference Intakes. Chapter of iodine. 2001.

% g

oite

r p

reva

len

ce

Median UIC (µg/dL)

Sources: USA-NHANES; UIC – 2007-2008, except non-pregnant and pregnant women 2005-2008, Caldwell et

al. Thyroid 2011; 21: 419; body weight 2003-2006, McDowell et al., Anthropometric reference data for children

and adults; National Health Statistics Report 2008; 10.

UIE (ug I/d) estimated by multiplying the reported UIC (ug I/L) for the calculated urinary volume

of each age- and gender group, based on body weight:

Urinary volume (L/d) = 0.009 L/h.kg x 24 h/d x wt (kg) – from IOM/ Academies of Sciences of

the USA: Dietary Reference Intakes for iodine and other nutrients. National Academy Press.

0

50

100

150

200

250

300

350

400

UIC(ug I/L)

Are we sure that we are interpreting well the UIC in pregnant women?

Years

0

50

100

150

200

250

300

350

400

UIC(ug I/L)

UIE(ug I/d)

Years

?

Reference figure: modified from DRI, IOM

of the Academies of Science of the USA.

95 150 1100 Iodine: µg/d

* Situation in Mexico: * females, ** men

345**

Assuming salt intakes: 7-16 g/d males, and 5-12 g/d*

females, and iodine content in salt of 30 mg I/kg

255*

30

Summary of the situation in Mexico -2013. Iodine intakes through salt.

*Based in: Correa et al. Mexico. Unpublished, 2014.

Minimum average: 95 µg I/5 g salt =

19 µg I /g salt =

19 mg I/kg

YearContent

[I] (mg/kg)Recommendation (WHO/UNICEF/ICC-IDD)

1996

20(average)

For providing 150 µg/day in 10 g salt/day = 150 µg/g , and 30% loss (150 x 1.3 = 19.5 µg/g) at the moment of production.

(40)(average)

Nothing is mentioned for salt intake of 5 g/day, but the range of ”averages” is stated 20-40 mg I/kg; a “range” was born.

15(average)

In households.

200015

(minimum)In posterior editions, the average became “minimum” and the concept of “adequate” iodized salt was born.

200720-40

(range)

“the percentage of food-grade salt with iodine content of between 20 and 40 ppm in a representative sample of households must be equal or greater than 90%”

31

How the concept of “adequate” iodized salt originated?

Parameter Coarse salt

n 32

Median (mg/kg) 23.8

Mean (mg I/kg) 39.9

S.D. (mg I/kg) 46.5

C.V. (%) 116.4%

% samples

< 20 mg I/kg33.4 %

% samples

< 15 mg I/kg29.6 %

32

Washed salt

42

29.7

30.9

10.0

32.4 %

13.8 %

5.6 %

Refined salt

20

33.7

33.9

2.9

7.6 %

0.0 %

0.0 %

Source: Unpublished results from Government Food Control (COFEPRIS), México, 2013.

Iodine content in different types of salt in México-2013 (Regulation: 30 ± 10 mg/kg)

33

Situation of the iodized salt in Mexico-2013;Regulation 30 ± 10 mg I/kg

10 40 60

0.15

0.30

0.45

0.60

Content (mg/kg)

Fre

quency

20 50 70 8030

Low variation

(refined salt)

Moderate variation

(washed salt)

Large variation

(coarse salt)

1. Nowadays, iodine is being supplied to most populations through iodized salt (discretionary –table and cooking- and salt used by food industries) or dairy products.

2. Almost all populations are receiving sufficient iodine, as the current iodine content in salt is between 25-45 mg I/kg, when only 15 mg I/kg in average would be sufficient for the current salt intakes.

3. The use of the “adequate” iodized salt (percent of samples below 15 mg I/kg) is causing confusion and it is an unfair parameter for qualifying the programmatic impact; many factors affect variation of the iodine content around the mean.

4. In general, a population median of iodine concentration in urine above 100 µg/L reflects good iodine intake in the whole population. The reference value for pregnant women is still pending.

5. Therefore, the 2 billion persons worldwide reported as at risk of suffering iodine deficiency is an exaggeration; iodized salt is one of the most successful programs of public health nutrition of the 20th Century.

Conclusions

34

19th BOARD MEETING 35

Assessing program performance and

potential for impact: the GAIN FACT tool

Lynnette Neufeld, PhD

Director, Monitoring, Learning and Research

36

Fortification has important impacts on

micronutrient status and on health outcomes –

but access to fortified foods and the conditions under which

they are stored, purchased, and used varies greatly within

and among countries

37

Fortified flour

is accessible

(available

and affordable)

in

communities

Households

use fortified

flour

appropriately

PO

LIC

IES

BE

HA

VIO

R C

HA

NG

E

CO

MM

UN

ICA

TIO

N

DE

LIV

ER

YQ

UA

LIT

YP

RO

DU

CT

ION

& S

UP

PL

Y

Households

increase

purchase of

fortified flour

/products

•Development &

implementation of:

nutrition policies,

fortification law,

regulations & standards

•Quality control &

assurance (mills &

commercial)

• Inspection and

auditing

Fortified flour

Imported,

produced &

distributed

meets quality

standards &

specifications

Providers/distributors

have knowledge

& motivation to

adequately

distribute, inform &

problem solve with

Women of

Reproductive Age

(WRA)

Households

know, demand,

accept, & have

ability to

appropriately use

fortified flour

Micronutrient

status of

individuals

improved

Micronutrient

Intake

increased

among those

at risk of low

micronutrient

intake

Other

interventions

Maternal

Morbidity

&

mortality

reduced

Child

morbidity

&

mortality

reduced

Cognition &

productivity

increased• Engagement of

stakeholders &

advocacy

• Development &

implementation of

intervention strategy

for consumer

information, education

& communication

• Flour industry

marketing

• Flour industry delivery

system

• Flour industry

management, training &

maintaining motivation

among providers &

distributors

Fortified flour

is available

in country

Anaemia &

neural tube

defects

decreased

•Production of fortified

flour by mills

•Importation of

fortified flour

•Micronutrient premix

Source: Flores 2013

Ma

na

gem

en

t, s

taff

, n

ati

on

al fo

rtif

ica

tio

n c

oa

liti

on

, fi

na

nc

ial

res

ou

rce

s, in

fra

str

uctu

re, o

the

r c

on

trib

uti

on

s f

rom

pa

rtn

ers

Knowledge &

Appropriate Use

Impact on Intake,

Status and FunctionAccess &

Coverage

Policies, Production, Delivery, Quality,

& Behavior Change Communication

38Coverge model from: Tanahashi Bull WHO 1978

To assess potential for impact we need to know

who consumes the food, how much, and how

much of the nutrient it actually contains

Contact coverage:

consume at least once per

week

Dietary contribution: %

Recommended Nutrient

Intakes (RNI)

Effective coverage:

requires some point of

comparison to how much is

needed

39

The Fortification Assessment Coverage Tool

(FACT)

• Proportion of the population that uses a

fortifiable food commodity, defined

appropriately for country, usually as

centrally produced (“contact coverage”)

• Intake of food from modified dietary recall

• Household

• Women of reproductive age; children

40

12 surveys in 10 countries:

~25,000 households representative of 1.5 billion people

41

Contact coverage of fortifiable* oil among

women of reproductive age (WRA)

0

10

20

30

40

50

60

70

80

90

100

Senegal Rajasthan, India Abidjan, Côted'Ivoire

% All

Poor

Non-poor

*Defined as commercially produced

42

Dietary contribution (% daily RNI) for vitamin A

met from consumption of fortified oil for WRA

0

10

20

30

40

50

60

70

80

90

100

Senegal Rajasthan, India Abidjan, Côted'Ivoire

% All

Poor

Non-poor

43

In Senegal, 51% of children 6 to 23 m of age

consume fortified oil at least once per week

% RNI estimated for all children who reported consuming oil at least once per week (51% of sample)

Consume fortifiable wheat flour at

least 1/week:

• 35% in rural South

• 51% in rural North

• 61% in peri-urban areas (exl. Dakar)

• 56% in Dakar

Mean (18.9%)

Median (13.3%)

44

Contact coverage of fortifiable* wheat flour

among WRA

0

10

20

30

40

50

60

70

80

90

100

Senegal Rajasthan, India Abidjan, Côted'Ivoire

% All

Poor

Non-poor

*Defined as commercially produced

45

Dietary contribution (% daily RNI) for iron met

by consumption of fortified wheat flour (WRA)

0

10

20

30

40

50

60

70

80

90

100

Senegal Rajasthan, India Abidjan, Côted'Ivoire

% All

Poor

Non-poor

Blue lines represented expected contribution following recommended fortification levels set by WHO

46

In Senegal, 57% of children 6 to 23 m of age

consume fortified wheat flour at least once

per week

% RNI estimated for all children who reported consuming wheat flour at least once per week (57% of sample)

Consume fortifiable wheat

flour at least 1/week:

• 51% of poor

• 67% of non-poor

Mean (21.6%)

Median (13.6%)

47

Contact coverage of iodized salt* by

households is moderate to high in all surveys

to date, but varies considerably by country

0

10

20

30

40

50

60

70

80

90

100

Rajasthan,India

Telangana,India

India(national)

Abidjan,Côte d'Ivoire

Bangladesh Ghana Senegal

%

All Poor Non-poor

*Reported as iodized

48

Utilization of salt that meets the standard*

however, is highly variable by country and

population group and very low in some contexts

0

10

20

30

40

50

60

70

80

90

100

Rajasthan,India

Telangana,India

India(national)

Abidjan,Côte d'Ivoire

Bangladesh Ghana Senegal

%

All Poor Non-poor

*Defined according to UNICEF/WHO standard of ≥ 15 ppm; except Abidjan data reported at country standard of ≥ 30 ppm

49

Hot off the press from Nigeria: Contact

coverage of fortifiable foods*

0

10

20

30

40

50

60

70

80

90

100

Oil Wheat flour Maize flour Salt Sugar

Kano State

Lagos State

*Preliminary results of recently completed survey. Fortifiable defined as commercially produced.

Includes all those mandated for fortification in Nigeria.

%

50

Hot off the press from Uganda: Contact

coverage of fortifiable foods*

0

10

20

30

40

50

60

70

80

90

100

Oil Wheat flour Maize flour Salt

Urban

Rural

National

*Preliminary results of recently completed survey. Fortifiable defined as commercially produced. Includes

all those mandated for fortification in Uganda.

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Limitations and areas of on-going work

A true measure of “effective coverage” requires an estimate of the

dietary gap in micronutrient intake that we wish to address with

fortification

– Our dietary intake method does not provide full dietary intake

estimate – exploring options to include this in future surveys

– E.g., Senegal – very high oil intakes are consistent with

previous surveys, but whether high vit A intake from oil is of

concern would depend on other sources in the diet

Our abbreviated dietary assessment estimate adapted from validated

methodologies, but as yet, not validated

– Recently completed survey in South Africa included 24-hr recall on

sub-set of population for comparison with our abbreviated tool

Results of these surveys contribute to evidence base, but ultimate

utility depends on their utilization for program improvement

– On-going (and planned) workshops and dissemination in country

to present and discuss and their implications for program

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Conclusions and implications

• Critical to know dietary patterns in the population to estimate

potential for impact, ensure fortification levels are set

appropriately and adjusted over time as dietary patterns change

• Investment in regular monitoring and surveillance and continual

feedback for program improvement, including enforcement to

standards is critical for impact and safety

• Substantial contribution to dietary intake of key

micronutrients from fortification programs:

• In some contexts, reaching rural, poor, children 6 to 23

mo of age, but considerable variation within and among

countries

• In all countries, quality control and enforcement requires

substantial improvement to identify and address under- and

over-fortification

Thank You

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