Abstract
Background: Large-scale food fortification (LSFF) of commonly consumed food vehicles is widely implemented in low- and middle-income countries. Many programs have monitoring information gaps and most countries fail to assess program coverage.Objective: The aim of this work was to present LSFF coverage survey findings (overall and in vulnerable populations) from 18 programs (7 wheat flour, 4 maize flour, and 7 edible oil programs) conducted in 8 countries between 2013 and 2015.Methods: A Fortification Assessment Coverage Toolkit (FACT) was developed to standardize the assessments. Three indicators were used to assess the relations between coverage and vulnerability: 1) poverty, 2) poor dietary diversity, and 3) rural residence. Three measures of coverage were assessed: 1) consumption of the vehicle, 2) consumption of a fortifiable vehicle, and 3) consumption of a fortified vehicle. Individual program performance was assessed based on the following: 1) achieving overall coverage ≥50%, 2) achieving coverage of ≥75% in ≥1 vulnerable group, and 3) achieving equity in coverage for ≥1 vulnerable group.Results: Coverage varied widely by food vehicle and country. Only 2 of the 18 LSFF programs assessed met all 3 program performance criteria. The 2 main program bottlenecks were a poor choice of vehicle and failure to fortify a fortifiable vehicle (i.e., absence of fortification).Conclusions: The results highlight the importance of sound program design and routine monitoring and evaluation. There is strong evidence of the impact and cost-effectiveness of LSFF; however, impact can only be achieved when the necessary activities and processes during program design and implementation are followed. The FACT approach fills an important gap in the availability of standardized tools. The LSFF programs assessed here need to be re-evaluated to determine whether to further invest in the programs, whether other vehicles are appropriate, and whether other approaches are needed.
Highlights
Large-scale food fortification (LSFF)6, the focus of the current article, relies on commonly consumed food vehicles to deliver micronutrients to as much of the general population as possible while trying to include a large proportion of members of vulnerable population groups who would stand to benefit most from additional micronutrients [1]
LSFF programs generally fall into 2 categories: 1) mandatory, whereby all producers of branded and packaged fortifiable foods should fortify the selected vehicles according to national legislation standards; and 2) voluntary, whereby producers may choose to fortify of their own accord, usually according to a national voluntary fortification standard
The results identified 2 major areas that programs need to focus on: 1) the selection of appropriate food vehicles before programs are started, and 2) routine monitoring of the fortification process to ensure that fortification occurs at the desired level
Summary
Large-scale food fortification (LSFF), the focus of the current article, relies on commonly consumed food vehicles (i.e., staple foods) to deliver micronutrients to as much of the general population as possible while trying to include a large proportion of members of vulnerable population groups who would stand to benefit most from additional micronutrients [1] This approach to delivering micronutrients has a long history of success to address inadequate dietary intake of essential nutrients in higher-resource countries [2,3,4,5], and is increasingly used in lowand middle-income countries to address a range of micronutrient deficiencies [1, 6, 7]. LSFF programs generally fall into 2 categories: 1) mandatory, whereby all producers of branded and packaged fortifiable foods should fortify the selected vehicles according to national legislation standards; and 2) voluntary, whereby producers may choose to fortify of their own accord, usually according to a national voluntary fortification standard The former should achieve higher coverage levels at the population level, assuming legislation standards are followed (i.e., producers are compliant).
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