Large-scale Food Fortification Research Articles

Current and potential contributions of large-scale food fortification to meeting micronutrient requirements in Senegal: a modelling study using household food consumption data

IntroductionMicronutrient deficiencies are common among women of reproductive age (WRA) and children in Senegal. Large-scale food fortification (LSFF) can help fill gaps in dietary intake.MethodsWe used household food consumption data...

The Policy of Compulsory Large-Scale Food Fortification in Sub-Saharan Africa.

Food fortification with micronutrients was initially justified in developed countries by a lack of availability of micronutrients in staple crops, mainly due to soil exhaustion. However, in Sub-Saharan arable lands, soil fatigue is not predominant, and communities consume mostly home-grown, organic, non-processed crops. Sub-Saharan food systems are nevertheless deeply entwined with food insecurity, driver of illnesses. Family production can promote subsistence, food stability, and self-sufficiency, the main SSA setback being the vicious cycle of poverty and the lack of dietary variety, contributing to malnutrition. Poverty reduction and women's education are significant strategies for reducing child and adolescent undernourishment. Fortification of foods consumed daily by individuals makes sense and can minimize, if not entirely, eliminate deficiencies. Compulsory mass fortification of foods in Sub-Saharan Africa (SSA) with single micronutrients is, however, controversial since they work in synergy among each other and with the food matrix, for optimal absorption and metabolism. Since the causes of malnutrition are many, caused by diverse, unequal, and unjust food distribution, interrelated with political, social, cultural, or economic factors, education status of the population, season and climatic changes, and effectiveness of nutrition programs, just food fortification cannot solve the composite of all these elements. Further, compulsory fortification is excessive, unproductive, and likely harmful to human health, while many challenges remain in assessing the quality of available premixes. Furthermore, aiming at dietary diversification is the best approach of increasing trace element intake from commonly accessible and easily available food sources.

The potential contributions of bouillon fortification to meeting micronutrient requirements among women and preschool children in Senegal: A modeling study using household consumption and expenditure survey data.

To reduce micronutrient deficiencies, Senegal mandates the fortification of refined oil with vitamin A and wheat flour with iron and folic acid. Expanding Senegal's large-scale food fortification programs to include fortified bouillon could help fill the remaining gaps in dietary micronutrient requirements. Using 7-day household food consumption data collected between 2018 and 2019, we assessed the potential contributions of bouillon fortified with vitamin A (40-250μg/g bouillon), folic acid (20-120μg/g), vitamin B12 (0.2-2μg/g), iron (0.6-5mg/g), and zinc (0.6-5mg/g) for meeting micronutrient requirements of women of reproductive age (WRA; 15-49 years old) and children (6-59 months old). Most households (90%) reported consuming bouillon, including poor and rural households. At modeled fortification levels, bouillon fortification reduced the national prevalence of inadequacy by up to ∼20 percentage points (pp) for vitamin A, 34 pp (WRA) and 20 pp (children) for folate, 20 pp for vitamin B12, 38 pp (WRA) and 30 pp (children) for zinc, and ∼8 pp for iron. Predicted reductions in inadequacy were generally larger among poor and rural populations, especially for vitamins A and B12. Our modeling suggests that bouillon fortification has the potential to substantially reduce dietary inadequacy of multiple micronutrients and could also help address inequities in dietary micronutrient inadequacies in Senegal.

Mandatory large-scale food fortification programmes can reduce the estimated prevalence of inadequate zinc intake by up to 50% globally

Large-scale food fortification (LSFF) can increase dietary micronutrient intake and improve micronutrient status. Here we used food balance sheet data from the Food and Agriculture Organization of the United Nations to estimate current country-specific prevalences of inadequate zinc intake. We assessed the potential effects of improving existing LSFF programmes for cereal grains or implementing new programmes in 40 countries where zinc deficiency is a potential public health problem. Accounting for LSFF programmes as currently implemented, 15% of the global population (1.13 billion individuals) is estimated to have inadequate zinc intake. In countries where zinc deficiency is a potential public health problem, the implementation of high-quality mandatory LSFF programmes that include zinc as a fortificant would substantially increase the availability of zinc in the national food supply, reducing the estimated prevalence of inadequate zinc intake by up to 50% globally. Investments in strong LSFF programmes could have a substantial impact on population zinc status.

Micronutrient-fortified bouillon as a strategy to improve the micronutrient adequacy of diets in Burkina Faso.

Bouillon is a promising candidate for fortification to complement existing large-scale food fortification (LSFF) programs. We used household dietary data from Burkina Faso to model potential contributions of bouillon fortified with vitamin A (40-250μg/g bouillon), folic acid (20-120μg/g), vitamin B12 (0.2-2μg/g), iron (0.6-5mg/g), and zinc (0.6-5mg/g) for meeting micronutrient requirements of women of reproductive age (15-49 years; WRA) and children (6-59 months). Most households (82%) reported bouillon consumption, with higher proportions of resource-constrained (84-88%) and rural households (88%) consuming bouillon. Accounting for the contributions of existing LSFF, household diets were inadequate to meet the micronutrient requirements of many WRA and children, exceeding 90% and 60% inadequacy for vitamins A and B12, respectively. Modeling results showed bouillon fortification could reduce inadequacy by up to ∼30 percentage points (pp) for vitamin A, ∼26 pp for folate among WRA (∼11 pp among children), ∼38 pp for vitamin B12, and 11-13 pp for zinc, with comparable reductions across socioeconomic strata and urban and rural residence. Predicted reductions in iron inadequacy were <3 pp. These results suggest dietary micronutrient inadequacies are a concern in Burkina Faso, and fortified bouillon can make substantial contributions to reducing micronutrient inadequacies, including among resource-constrained and rural populations.

Assessment of the policy enabling environment for large-scale food fortification: A novel framework with an application to Kenya.

Large-scale food fortification (LSFF) programs have potential to improve a population's nutritional status. Though their success depends heavily on the prevailing policy environment, few tools exist to understand this environment. To address this gap, we develop a novel framework to define and assess the policy enabling environment for LSFF. This easy-to-apply framework can be used in any setting to track progress and identify next steps for continued improvements. The policy enabling environment is conceptualized as having three domains-policy agenda setting, policy implementation, and policy monitoring and evaluation-each of which is captured through indicators that can be evaluated using existing documentation, key informant interviews, and/or a survey of stakeholder perceptions. To validate the framework and demonstrate how it can be operationalized, we apply it in Kenya, where a mandatory LSFF program for salt has been in place since 1978, and a program for packaged maize and wheat flours and vegetable oils was introduced in 2012. Per our assessment, Kenya has achieved the greatest success within the domain of policy agenda setting, has realized moderate success in policy implementation, and has a weaker record in policy monitoring and evaluation. The positive trajectory for many indicators points to a promising future for Kenya's LSFF program. This assessment yields policy implications for Kenya to improve its policy environment for LSFF, especially around financial sustainability of the program; ways to improve the processes for surveillance and enforcement; efforts to support fortification among medium-and small-scale millers; and a need to improve the data landscape.

Estimating food consumption, micronutrient intake and the contribution of large-scale food fortification to micronutrient adequacy in Tanzania.

To assess the potential contribution of large-scale food fortification (LSFF) towards meeting dietary micronutrient requirements in Tanzania. We used household food consumption data from the National Panel Survey 2014-15 to estimate fortifiable food vehicle coverage and consumption (standardised using the adult female equivalent approach) and the prevalence at risk of inadequate apparent intake of five micronutrients included in Tanzania's fortification legislation. We modelled four LSFF scenarios: no fortification, status quo (i.e. compliance with current fortification contents) and full fortification with and without maize flour fortification. Tanzania. A nationally representative sample of 3290 Tanzanian households. The coverage of edible oils and maize and wheat flours (including products of wheat flour and oil such as bread and cakes) was high, with 91 percent, 88 percent and 53 percent of households consuming these commodities, respectively. We estimated that vitamin A-fortified oil could reduce the prevalence of inadequate apparent intake of vitamin A (retinol activity equivalent) from 92 percent without LSFF to 80 percent with LSFF at current fortification levels. Low industry LSFF compliance of flour fortification limits the contribution of other micronutrients, but a hypothetical full fortification scenario shows that LSFF of cereal flours could substantially reduce the prevalence at risk of inadequate intakes of iron, zinc, folate and vitamin B12. The current Tanzania LSFF programme likely contributes to reducing vitamin A inadequacy. Policies that support increased compliance could improve the supply of multiple nutrients, but the prominence of small-scale maize mills restricts this theoretical benefit.

Development of a standardized consensus lexicon for terms related to micronutrient programs.

Inconsistent use of terminology among diverse stakeholders hinders effective communication in micronutrient programs, especially large-scale food fortification (LSFF) which involves stakeholders from different sectors. To align the terminology use, the Micronutrient Data Innovation Alliance (DInA) of the Micronutrient Forum (MNF) created a lexicon of terms related to LSFF and other micronutrient programs. The purpose of this lexicon is to establish a central repository of consensus definitions of key terms to facilitate communication among diverse stakeholders involved in micronutrient programs including public and private sectors, donor agencies, food industries, academic institutions, etc. This paper describes the methodology of lexicon development. Important terms related to micronutrient programs were compiled from multiple sources, including United Nations agencies, program implementation and technical support agencies, relevant websites, and scientific literature. The selection of terms was guided by key micronutrient interventions (fortification, supplementation, dietary diversification) and the program cycle (assessment, planning, implementation, monitoring and evaluation). Definitions of terms were identified from these references and checked for consistency across different sources. For terms with multiple definitions, a modified Delphi method was applied to harmonize the definitions. The first draft lexicon (n = 113 terms) was reviewed by six experts from the University of California, Davis (UCD) and MNF, and second draft (n = 115 terms) was shared with 24 global micronutrient experts for feedback. Fifty-four terms were found to have multiple definitions. Of which, minor modification was made for 12-terms with nominal difference and remaining 42-terms were shared with over 140 micronutrient-experts disseminated via an online survey through newsletters and emails to solicit experts' opinions on the most appropriate definition or a modified one. Nineteen legal terms and 83 micronutrient terms (n = 102 terms) were subsequently added. Overall, 39 experts from diverse areas of expertise (LSFF, micronutrient program planning and implementation, surveys and research, policy development, food industry regulations, food safety, and public health nutrition) participated in the online survey. The terms with >75% agreement among experts were considered as final, while the remaining were reviewed again by experts from UCD and MNF until consensus was reached on harmonized definitions. The current lexicon is available online at the DInA-website. and contains 217 terms and will be maintained as a "living document". The lexicon will facilitate the ability of key stakeholders of micronutrient programs to evaluate and compare program performance in order to make informed decisions on how to ensure future progress in reducing micronutrient deficiencies.

Emerging Opportunities for Restructuring Livestock Products and Supply Chains in Post-COVID-19 in India: A Review

The outbreak of COVID-19 has vividly tested the resilience of the livestock sector in India. During this process, a volume of current and potential opportunities has also arisen to redesign livestock products and supply chains. The study reviewed systematic observations to enhance productivity, product quality, and traceability in the livestock sector of India. The study explored the nature of recent digitization and remote monitoring through sensors, food development, and supply chain remodelling to assess post-pandemic acceleration toward modern production and marketing channels. An extensive review of the studies revealed that the emergence of organized micro-delivery channels had created a vast market scope to modernize distribution supply chains, where real-time production chains provided seamless transmission of information among all the stakeholders. The study revealed that the Government should encourage agri-tech startups, which can play a crucial role in propagating organized and hybrid supply chains. Further, livestock value-added product development through large-scale food fortification (LSFF) can help to reduce nutritional deficiency. Therefore, the study concluded that redesigning supply chains and value-added product development in the livestock sector are crucial to inclusive and sustainable agricultural development.

Acceptability of Multiple Micronutrient-Fortified Bouillon Cubes among Women and Their Households in 2 Districts in The Northern Region of Ghana

BackgroundBouillon is a promising large-scale food fortification vehicle, but there is uncertainty regarding the types and concentrations of micronutrients that are feasible to add without compromising consumer acceptability. ObjectiveThe objective of this study was to evaluate the acceptability of 2 different multiple micronutrient-fortified bouillon cube formulations, compared with a bouillon cube fortified with iodine only. MethodsWe conducted a double-blind, randomized, controlled acceptability study in 2 districts in northern Ghana. Two nonproprietary, noncommercialized formulations of multiple micronutrient-fortified bouillon cubes containing iron, zinc, folic acid, vitamins A and B12, and iodine at “upper-level” (45-125% CODEX NRV/2.5g) or “lower-level” (15-50% CODEX NRV/2.5g) concentrations, and a control cube that contained iodine only (50% CODEX NRV/2.5g) were evaluated. Eligible women (n = 84) were invited to participate in 1) center-based sensory evaluations designed to permit within-individual comparisons among the different study products; and 2) in-home evaluation of bouillon acceptability and use, in which participants were randomized to receive 1 of the 3 study products to use in household cooking for a 2-wk period. Acceptance test ratings were based on a 5-point Likert scale (1 = dislike very much, 5 = like very much). ResultsIn the center-based evaluations, overall liking of the 3 bouillon cube formulations both dry and in prepared dishes ranged from 4.3 to 4.6 on the 5-point Likert scale and did not differ among formulations (P > 0.05). After the 2-wk in-home trial, 93.8% of index participants (n = 75/80) rated their overall liking of the bouillon product formulation to which they were randomly assigned as “like” or “like very much” (4–5 on the 5-point Likert scale) and median apparent intake of study-provided bouillon over 2 wk was 3.6 g/capita/d; neither value differed by study group (P = 0.91 for both). ConclusionsAll 3 formulations of bouillon cubes assessed were acceptable to women and their households in 2 districts in northern Ghana.This trial was registered at www.clinicaltrials.gov as NCT05177614.

Global Coverage of Mandatory Large-Scale Food Fortification Programs: A Systematic Review and Meta-Analysis.

Food fortification with micronutrients is widely implemented to reduce micronutrient deficiencies and related outcomes. Although many factors affect the success of fortification programs, high population coverage is needed to have a public health impact. We aimed to provide recent global coverage estimates of salt, wheat flour, vegetable oil, maize flour, rice, and sugar among countries with mandatory fortification legislation. The indicators were the proportion of households consuming the: food, fortifiable food (that is, industrially processed), fortified food (to any extent), and adequately fortified food (according to national or international standards). We estimated the number of individuals reached with fortified foods. We systematically retrieved and reviewed all applicable evidence from: published reports and articles from January 2010 to August 2021, survey lists/databases from key organizations, and reports/literature received from key informants. We analyzed data with R statistical package using random-effects meta-analysis models. An estimated 94.4% of households consumed salt, 78.4% consumed fortified salt (4.2 billion people), and 48.6% consumed adequately fortified salt in 64, 84, and 31 countries, respectively. Additionally, 77.4% of households consumed wheat flour, 61.6% consumed fortifiable wheat flour, and 47.1% consumed fortified wheat flour (66.2 million people) in 15, 8, and 10 countries, respectively, and 87.0% consumed vegetable oil, 86.7% consumed fortifiable oil, and 40.1% consumed fortified oil (123.9 million people) in 10, 7, and 5 countries, respectively. Data on adequately fortified wheat flour and vegetable oil and coverage indicators for maize flour, rice, and sugar were limited. There are major data gaps on fortification coverage for most foods except salt. All countries with mandatory fortification programs should generate and use more coverage data to assess program performance and adjust programs as needed to realize their potential to reduce micronutrient deficiencies (PROSPERO CRD42021269364).

A generic theory of change-based framework with core indicators for monitoring the effectiveness of large-scale food fortification programs in low- and middle-income countries.

Large-scale food fortification (LSFF) programs are widely implemented in low- and middle-income countries (LMIC) to alleviate micronutrient deficiencies. However, these programs may not achieve the desired impact due to poor design or bottlenecks in program implementation. Monitoring and evaluation (M&E) frameworks and a set of agreed indicators can help to benchmark progress and to strengthen the evidence-base of effectiveness in a standardized way. We aimed to formulate recommendations towards core indicators for evaluating the effectiveness of LSFF programs with their associated metrics, methods, and tools (IMMT). For this, we used a multi-method iterative approach, including a mapping review of the literature, semi-structured interviews with international experts, compilation of a generic Theory of Change (ToC) framework for LSFF program delivery, and selection of IMMT for M&E of LSFF programs at key stages along the ToC delivery framework. Lastly, we conducted exploratory, qualitative interviews with key informants in Nigeria to explore experiences and perceptions related to the implementation of LSFF programs in Nigeria's context, and their opinion towards the proposed set of core IMMT. The literature search resulted in 14 published and 15 grey literature documents, from which we extracted a total of 41 indicators. Based on the available literature and interviews with international experts, we mapped a ToC delivery framework and selected nine core indicators at the output, outcome and impact level for M&E of the effectiveness of LSFF programs. Key informants in Nigeria revealed that the main bottlenecks for implementation of the proposed IMMT are related to the lack of technical capacity, equipment, laboratory infrastructure, and financial resources. In conclusion, we propose a set of nine core indicators for enabling comprehensive M&E of the effectiveness of LSFF programs in LMIC. This proposed set of core indicators can be used for further evaluation, harmonization and integration in national and international protocols for M&E of LSFF programs.

Household-Level Coverage of Iron-Biofortified Beans in the Northern Province of Rwanda

BackgroundBiofortification, the process of enhancing the micronutrient content of staple crops, is a nutrition-sensitive agricultural intervention with the potential to increase micronutrient intakes and improve health outcomes, especially among vulnerable populations. Although data are available on the number of farming households that grow biofortified crops, information on the coverage of biofortified foods in the general population is limited. Such information is critical to assess the performance of biofortification programs and guide decisions related to program implementation while ascertaining progress toward achieving expected impacts. ObjectiveThis study aimed to assess the household coverage of iron-biofortified beans (IBBs) in rural areas of the Northern Province of Rwanda. MethodsWe applied methods previously used to assess coverage in large-scale food fortification programs to develop coverage indicators for IBBs. These indicators were 1) consumption of beans in any form; 2) awareness of IBBs; 3) availability of IBBs; 4) consumption of IBBs (ever); and 5) consumption of IBBs (current). ResultsOf the 535 households surveyed, 98% consumed beans in any form and 79% were aware of IBBs. Among the 321 households that provided bean samples, only 40% of the samples were biofortified (as determined by a breeding specialist) and only 21% of respondents were able to correctly identify IBBs. Although 52% of households reported to be ever consuming biofortified beans, only 10% of households were currently consuming these beans. ConclusionsDespite relatively high awareness of IBBs among surveyed households, a few households currently consume IBBs, highlighting the need to explore strategies to promote consumption. More research is also required to investigate factors hindering the consumption of IBBs.

Global strategies for the prevention of neural tube defects through the improvement of folate status in women of reproductive age.

Neural tube defects represent a global public health problem, mainly in countries where effective prevention strategies are not yet in place. The global prevalence of neural tube defects is estimated at 18.6/10,000 (uncertainty interval: 15.3-23.0) live births, where ~ 75% of cases result in under-five mortality. Most of the mortality burden is in low- and middle-income countries. The main risk factor for this condition is insufficient folate levels in women of reproductive age. This paper reviews the extent of the problem, including the most recent global information on folate status in women of reproductive age and the most recent estimates of the prevalence of neural tube defects. Additionally, we provide an overview of the available interventions worldwide to reduce the risk of neural tube defects by improving folate status in the population, including dietary diversification, supplementation, education, and fortification. Large-scale food fortification with folic acid is the most successful and effective intervention to reduce the prevalence of neural tube defects and associated infant mortality. This strategy requires the coordination of several sectors, including governments, the food industry, health services providers, the education sector, and entities that monitor the quality of the service processes. It also requires technical knowledge and political will. An international collaboration between governmental and non-governmental organizations is essential to succeed in saving thousands of children from a disabling but preventable condition. We propose a logical model for building a national-level strategic plan for mandatory LSFF with folic acid and explain the actions needed for promoting sustainable system-level change.

Aligning the Epidemiology of Malnutrition with Food Fortification: Grasp Versus Reach

Large-scale food fortification (LSFF) has been recognized as one of the most cost-effective interventions to improve the intake of vitamins and minerals and decrease the burden of micronutrient deficiency. Indeed, the simple addition of micronutrients to staple foods, such as wheat, maize and rice, or condiments, including salt and bouillon, has tremendous potential to impact malnutrition. However, most LSFF programs have been poorly designed and have not taken into consideration critical inputs, including current levels of nutrient inadequacy and per capita consumption of different food vehicles when deciding which nutrients to add and at what concentrations. LSFF programs, like some other nutrition interventions, also tend to have low coverage and reach and lack monitoring to measure this and course correct. These program design flaws have resulted in limited effectiveness and have made it difficult to determine how best to harmonize LSFF with other interventions to reduce micronutrient deficiencies, including efforts to enhance dietary diversity, biofortification and supplementation. Furthermore, LSFF has often been touted as a population-based intervention, but in fact has heterogenous effects among sub-groups, particularly those with limited access to or inability to afford fortified foods, as well as those with higher physiological requirements, such as pregnant and lactating women. This article focuses on these limitations and the concerted efforts underway to improve the collection, analysis, and use of data to better plan LSFF programs, track implementation, and monitor coverage and impact. This includes a more sophisticated secondary analysis of existing data, innovations to increase the frequency of primary data collection and programmatically relevant visualizations of data of sub-national estimates. These improvements will enable better use of data to target resources and programmatic efforts to reach those who stand to benefit most from fortification.

Estimating the cost and cost-effectiveness of adding zinc to, and improving the performance of, Burkina Faso's mandatory wheat flour fortification programme.

Zinc is an essential micronutrient that promotes normal growth, development and immune function. In the context of persistent dietary zinc inadequacies, large-scale food fortification can help fill the gap between intake and requirements. Burkina Faso mandates wheat flour fortification with iron and folic acid. We used activity-based cost modelling to estimate the cost of adding zinc to the country's wheat flour fortification standard assuming (1) no change in compliance with the national standard, and (2) a substantial improvement in compliance. We used household food consumption data to model effective coverage, that is, the number of women of reproductive age (WRA) predicted to achieve adequate zinc density (zinc intake/1000 kcal) with the addition of fortification to diets. Without interventions, the prevalence of inadequate dietary zinc density was ~35.5%. With no change in compliance, the annual average incremental cost of adding zinc to fortified wheat flour was $10,347, which would effectively cover <1% of WRA at an incremental cost of ~$0.54/WRA effectively covered. Improving compliance added ~$300,000/year to the cost of the fortification programme without zinc; including zinc added another ~$78,000/year but only reduced inadequate intake among WRA by 3.6% at an incremental cost of ~$0.45/WRA effectively covered. Although the incremental cost of adding zinc to wheat flour is low ($0.01/wheat flour consumer/year), given low levels of wheat flour consumption, zinc fortification of wheat flour alone contributes marginally to, but will not fully close, the dietary zinc gap. Future research should explore potential contributions of zinc to a broader set of delivery vehicles.

Coverage of Large-Scale Food Fortification of Edible Oil, Wheat Flour, and Maize Flour Varies Greatly by Vehicle and Country but Is Consistently Lower among the Most Vulnerable: Results from Coverage Surveys in 8 Countries

Coverage of Large-Scale Food Fortification of Edible Oil, Wheat Flour, and Maize Flour Varies Greatly by Vehicle and Country but Is Consistently Lower among the Most Vulnerable: Results from Coverage Surveys in 8 Countries

Comparison of the costs and data outputs of conventional cluster sampling and lot quality assurance sampling (LQAS) for assessing the coverage of fortified foods in household surveys

Household surveys are essential for assessing the coverage of public health programmes, including large-scale food fortification (LSFF) programmes in developing countries. For decades, survey implementers have predominantly designed and implemented household-based surveys using conventional cluster sampling, but other sampling approaches, such as lot quality assurance sampling (LQAS), should be considered as an alternative. This study compares the costs and data outputs of conventional cluster sampling and LQAS when used to measure the household-level coverage of a hypothetical LSFF programme. Specifically, four survey scenarios were compared using hypothetical results: conventional cluster sampling to calculate the coverage of fortified foods at the national (scenario A) and regional (scenario B) levels, and LQAS to produce pass/fail results at the national (scenario C) and regional (scenario D) levels. For each scenario, sample sizes were calculated using a target coverage of 25%, 50%, and 75%, and used previous surveys to estimate survey budget costs, which consisted of the costs of administration, field workers, other personnel, materials, and laboratory testing. A national level LQAS survey (scenario C) had the lowest estimated costs (69,424 – 73,462 USD), followed by a national level conventional cluster sampling survey (scenario A) (82,620 – 90, 164 USD). There were higher overall costs and larger cost differences between sampling approaches for surveys designed to yield regional estimates. Here, costs for a conventional cluster sampling survey (scenario B; 212,210 – 251, 470 USD) are more than double those for a LQAS survey (scenario D) (113,060 – 129,540 USD). Sample size is the main driver of survey costs in all scenarios, while costs for field teams (salaries and transportation) and laboratory analyses of food samples vary depending on the scenario and coverage threshold; all other survey costs (e.g., ethical approaval, training &amp; field testing) remain relatively stable across different scenarios and thresholds. While LQAS surveys can be implemented at a lower cost due to smaller sample size requirements, the cost savings are less than expected due to the more dispersed distribution of households. Furthermore, because LQAS are initially designed to yield only pass/fail classification rather than estimates of actual coverage, they may not provide the actionable insights required in routine programme monitoring. When selecting a survey sampling approach, food fortification programme planners must consider what type of results best suit their decision-making needs and available resources. Key words: Coverage, Food Fortification, Sampling, Lot-Quality Assurance Sampling, Cluster-sampling

Building the Commitment of the Private Sector and Leveraging Effective Partnerships to Sustain Food Fortification.

The private sector is a critical partner in achieving the universally adopted Sustainable Development Goals (SDGs)-UNDP 2022. As part of a national strategy to address malnutrition (SDG2), Large-Scale Food Fortification of commonly consumed staple foods and condiments with vitamins and minerals is a proven intervention that requires the concerted engagement of multiple actors in a country's agri-food and public health ecosystems. Lessons from TechnoServe's Strengthening African Processors of Fortified Foods (SAPFF) Program, implemented from 2016 to 2022 in Kenya, Nigeria, and Tanzania with support from the Bill and Melinda Gates Foundation, provide essential learnings about how to effectively engage, motivate, and improve the food fortification performance of the industry in compliance with national standards, through capacity building, responsive technical assistance, and multistakeholder engagement that builds trust and accountability of industry in the fight against malnutrition.

Estimating the Costs of Alternative Large-Scale Food Fortification Programs in Burkina Faso: A MINIMOD Tool for Informing Policy Discussions

ObjectivesDecisions regarding the types and amounts of micronutrients to include in large-scale food fortification (LSFF) programs should consider costs. The Micronutrient Intervention Modeling (MINIMOD) cost tool estimates the costs of alternative LSFF programs, with focus on stakeholders’ cost burdens.MethodsAn activity-based cost model was developed and adapted to the context of Burkina Faso. Key national characteristics (e.g., population size), and information on existing and hypothetical LSFF programs (e.g., adherence to standards) establish the model's platform. Private- and public-sector costs (as relevant) of designing, implementing, and managing LSFF are included. The model contains a micronutrient premix cost calculator. LSFF-vehicle-specific consumption patterns (e.g., g/day of fortifiable wheat flour consumed, based on household survey data) link costs to program reach. A ten-year planning time horizon is adopted.ResultsThe premix required to fortify wheat flour with iron and folic acid (60 mg/kg of ferrous fumarate, 2.5 mg/kg of folic acid – the current standard) is estimated to cost ∼$2.11 (2020 USD) per MT of fortified flour, with overall 10-year program costs of ∼$2.4m; ∼25% faced by industry (e.g., internal quality control), ∼23% by government (e.g., external monitoring), and 52% by stakeholders who would cover premix costs (generally assumed to be industry, with some pass-through to consumers). Cost per person and cost per person reached are ∼$0.010 and ∼$0.023, respectively. Including zinc in this premix (95 mg/kg of zinc oxide) would increase the cost per MT of fortified flour to ∼$3.02, total 10-year program costs to ∼$3.3m, and cost per person and per person reached to ∼$0.014 and ∼$0.032, respectively. The premix's share of costs increased to ∼54%.ConclusionsThe levels and compositions of the costs should be considered when designing and managing LSFF, in part because different stakeholder groups, including consumers, will be called upon to pay them. Premix costs are one main cost driver; increasing the number and/or amounts of fortificants will increase overall program costs and shift the burden of costs among stakeholders.Funding SourcesResearch was supported by a grant to UC Davis from Helen Keller International through their support from the Bill & Melinda Gates Foundation.