Abstract
ABSTRACTBackgroundSince 2011 Cameroon has mandated the fortification of refined vegetable oil with vitamin A and wheat flour with iron, zinc, folic acid, and vitamin B-12. In 2012, measured fortification levels for flour, and particularly oil, were below target.ObjectivesWe assessed Cameroon's food fortification program using a program impact pathway (PIP) to identify barriers to optimal performance.MethodsWe developed a PIP through literature review and key informant interviews. We conducted interviews at domestic factories for refined vegetable oil (n = 9) and wheat flour (n = 10). In 12 sentinel sites distributed nationally, we assessed availability and storage conditions of fortified foods in markets and frequency of consumption of fortified foods among women and children (n = 613 households). Food samples were collected from factories, markets, and households for measurement of micronutrient content.ResultsTwo-thirds of factories presented quality certificates for recent premix purchases. All factories had in-house capacity for micronutrient analysis, but most used qualitative methods. Industries cited premix import taxes and access to external laboratories as constraints. Mean vitamin A levels were 141% (95% CI: 116%, 167%), 75% (95% CI: 62%, 89%), and 75% (95% CI: 60%, 90%) of target in individual samples from factories, markets, and households, respectively. Most industry flour samples appeared to be fortified, but micronutrient levels were low. Among composite flour samples from markets and households, the mean iron and zinc content was 25 mg/kg and 43 mg/kg, respectively, ∼45% of target levels; folic acid (36%) and vitamin B-12 (29%) levels were also low. In the previous week, the majority of respondents had consumed “fortifiable” oil (63% women and 52% children) and wheat flour (82% women and 86% children).ConclusionsIn Cameroon, oil fortification program performance appears to have improved since 2012, but fortification levels remain below target, particularly for wheat flour. Consistent regulatory monitoring and program support, possibly through premix procurement and micronutrient analysis, are needed.
Highlights
Different forms of malnutrition, including micronutrient deficiencies, contribute significantly to the burden of mortality and morbidity among young children and women of reproductive age [1]
In Cameroon, oil fortification program performance appears to have improved since 2012, but fortification levels remain below target, for wheat flour
We aimed to provide insights into the challenges and opportunities for sustaining large-scale food fortification programs using the case of mandatory fortification of vegetable oil and wheat flour in Cameroon
Summary
Different forms of malnutrition, including micronutrient deficiencies, contribute significantly to the burden of mortality and morbidity among young children and women of reproductive age [1]. Staple food fortification is 1 strategy to reduce micronutrient deficiencies [2,3,4] in a costeffective manner [5,6,7]. Large-scale fortification programs have been implemented throughout many low- and middle-income countries in Africa, Asia, and South America [8, 9]. Such programs are often advocated as “sustainable,” with the rationale that once the program is Keywords: fortification, micronutrient, program impact pathway, implementation science, monitoring launched, the effort to maintain the process is minimal, and the recurring costs for micronutrient premix procurement and industry compliance monitoring are absorbed by the consumer or the government. In 2012, measured fortification levels for flour, and oil, were below target
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