Large-scale Food Fortification Research Articles

Modeling food fortification contributions to micronutrient requirements in Malawi using Household Consumption and Expenditure Surveys.

Large‐scale food fortification may be a cost‐effective intervention to increase micronutrient supplies in the food system when implemented under appropriate conditions, yet it is unclear if current strategies can equitably benefit populations with the greatest micronutrient needs. This study developed a mathematical modeling framework for comparing fortification scenarios across different contexts. It was applied to model the potential contributions of three fortification vehicles (oil, sugar, and wheat flour) toward meeting dietary micronutrient requirements in Malawi through secondary data analyses of a Household Consumption and Expenditure Survey. We estimated fortification vehicle coverage, micronutrient density of the diet, and apparent intake of nonpregnant, nonlactating women for nine different micronutrients, under three food fortification scenarios and stratified by subpopulations across seasons. Oil and sugar had high coverage and apparent consumption that, when combined, were predicted to improve the vitamin A adequacy of the diet. Wheat flour contributed little to estimated dietary micronutrient supplies due to low apparent consumption. Potential contributions of all fortification vehicles were low in rural populations of the lowest socioeconomic position. While the model predicted large‐scale food fortification would contribute to reducing vitamin A inadequacies, other interventions are necessary to meet other micronutrient requirements, especially for the rural poor.

Rapid direct analysis of retinyl palmitate (vitamin A) in fortified vegetable oils by HPLC-FLD

ABSTRACT Large-scale food fortification of vegetable oils with vitamin A has been implemented successfully for decades in numerous African and Asian countries, contributing demonstrably to reductions in vitamin A deficiency. For these programmes, reliable and validated analytical data are essential to demonstrate compliance with legal standards and fortification levels. Commonly, many analytical laboratories use a saponification method for the quantitative analysis of retinyl palmitate (the mostly used form of vitamin A for fortification) in fortified oils, which implies a multiple-step procedure with long analysis times and the potential risk of analyte loss. The aim of the present study was to develop and validate a direct High-performance Liquid Chromatography (HPLC) method that reduces these sample preparation steps, leading to the cost- and time-efficient quantification of retinyl palmitate in fortified oils. Oil samples are dissolved into the HPLC solvents, then injected directly into a common C18 column, and subsequently detected by a fluorescence detector. The limit of quantification (1.0 mg retinyl palmitate kg−1) and the working range of 1.0–100 mg retinyl palmitate kg−1 with a linearity of R2 = 0.9989 are appropriate to analyse fortified oil samples. The method also showed adequate precision (RSD between 1.1% and 3.1%) and recoveries (86–103%) at two different concentration levels. The accuracy of the direct HPLC method was additionally proven by the comparison of spiked samples with two external laboratories that used the saponification method. The robustness of the method was confirmed by the analysis of various spiked edible oils. The HPLC column is not deteriorated by the lipid matrix and shows excellent stability and long lifetime. Also, 9-cis-retinyl palmitate formed mainly by light exposure could be detected by this method. The direct HPLC method is a well-suited alternative to the saponification method for the rapid and reliable routine analysis of fortified oil samples.

Achieving dietary micronutrient adequacy in a finite world

Achieving dietary micronutrient adequacy in a finite world

Understanding drivers of private-sector compliance to large-scale food fortification: A case study on edible oil value chains in Bangladesh

Micronutrient deficiency is a pertinent global challenge that affects billions of people and has deleterious health effects. Large-scale food fortification (LSFF) is a cost- effective way to tackle micronutrient deficiency and improve health outcomes, particularly in low- and middle-income countries (LMICs). However, the success of LSFF in LMICs is often hampered by limited compliance with fortification mandates by the private sector, who supply fortified foods. In this paper, we use a case study of the edible oil produced in Bangladesh to analyze the factors facilitating and impeding this compliance by for-profit actors. We identified four bottlenecks that disincentivize private sector actors’ decision to comply. First, fortified and non-fortified products co-exist in the market, disincentivizing producers to invest in fortification. Second, the lack of traceability reduces the risk for large-scale producers’ non-compliance with the regulation. Third, small-scale producers face economic pressures that prevent them from adequately fortifying oil products. Lastly, law enforcement is currently inconsistent, allowing the supply of under-fortified oil in the market. Given the evidence, we recommend to strengthen the control of bulk item fortification through more frequent and rigorous surveillance at the production level. This will ensure that resource constrained consumers who also have the greatest potential to benefit from added nutrients, remain able to access affordable and nutrient-enriched food.

Enablers and Barriers of Zinc Fortification; Experience from 10 Low- and Middle-Income Countries with Mandatory Large-Scale Food Fortification.

Adequate zinc nutrition is important for child growth, neurodevelopment, immune function, and normal pregnancy outcomes. Seventeen percent of the global population is estimated to be at risk for inadequate zinc intake. However, zinc is not included in the fortification standards of several low- and middle-income countries with mandatory fortification programs, despite data suggesting a zinc deficiency public health problem. To guide policy decisions, we investigated the factors enabling and impeding the inclusion of zinc as a fortificant by conducting in-depth interviews with 17 key informants from 10 countries. Findings revealed the decision to include zinc was influenced by guidance from international development partners and enabled by the assessment of zinc deficiency, mandatory regional food fortification standards which included zinc, the World Health Organization (WHO) guidelines for zinc fortification, and the low cost of zinc compound commonly used. Barriers included the absence of zinc from regional fortification standards, limited available data on the efficacy and effectiveness of zinc fortification, and the absence of national objectives related to the prevention of zinc deficiency. To promote zinc fortification there is a need to put the prevention of zinc deficiency higher on the international nutrition agenda and to promote large-scale food fortification as a key deficiency mitigation strategy.

The Cost-Effectiveness of Existing and Hypothetical Iron Fortification Programs in Haiti

Abstract Objectives Our objectives were to estimate apparent intake of iron in Haiti, to assess the adequacy of iron intake among women of reproductive age (WRA), and to model the cost-effectiveness of fortifying alternative food vehicles for reducing inadequate intake. Methods We analyzed the most recent Haiti household food consumption data (2012 ECVMAS) to estimate adequacy of apparent iron intake from dietary sources (using the adult male equivalent method; assuming 10% absorption) and modeled the impacts of fortifying currently mandated (wheat flour, applying local data on current compliance) and hypothetical (bouillon and rice) food vehicles on reductions in the prevalence of inadequate iron intake (effective coverage). We built activity-based cost models to estimate large scale food fortification (LSFF) program establishment and management costs, based on key informant interviews and on published cost estimates from other settings adapted to fit the Haitian case. Results The prevalence of inadequate dietary intake of iron among WRA was 79% (100% among pregnant women). Iron-fortified wheat flour was the most cost-effective vehicle: $4.32 and $4.75 per WRA-year effectively covered at current (75% of flour fortified to the standard of 30 mg/kg) and target (90% fortified to the standard) fortification levels. Fortified wheat flour effectively covered 11–13% of non-pregnant WRA, but almost no pregnant women. Although bouillon was consumed by > 98% of households, low estimated iron absorption from fortified bouillon (2%) led to low effective coverage. Iron-fortified rice (90% fortified at 120 mg/kg) was predicted to effectively cover the largest number of WRA (reducing inadequate intake to ∼30%), but at a cost of $7.80 per WRA-year effectively covered. Conclusions Of the food vehicles modeled, wheat flour was the most cost-effective for reducing inadequate iron intake. Modeling iron fortification of individual and combinations of food vehicles showed that well-designed LSFF programs can contribute to improving iron status among non-pregnant women, but eliminating inadequate iron intake among all WRA will require complementary iron interventions. Funding Sources This work was supported by grants to UC Davis from the Global Alliance for Improved Nutrition (GAIN) and to Partners of the Americas from the United States Agency for International Development (USAID).

Food Fortification: The Advantages, Disadvantages and Lessons from Sight and Life Programs.

Deficiencies in one or more micronutrients such as iron, zinc, and vitamin A are widespread in low- and middle-income countries and compromise the physical and cognitive capacity of millions of people. Food fortification is a cost-effective strategy with demonstrated health, economic and social benefits. Despite ongoing debates globally and in some countries regarding the performance and safety of food fortification, the practice offers significant benefits across each of the main vehicles for food fortification (large-scale food fortification, biofortification and point-of-use or home fortification) ranging from reducing the prevalence of nutritional deficiencies and economic benefits to societies and economies. Using Sight and Life’s global and national experiences in implementing food fortification efforts, we demonstrate how different programs in LMICs have successfully addressed challenges with food fortification and in doing so, find that these efforts are most successful when partnerships are formed that include the public and private sector as well as other parties that can provide support in key areas such as advocacy, management, capacity building, implementation and regulatory monitoring.

Large-scale food fortification has great potential to improve child health and nutrition.

Undernutrition, including micronutrient deficiencies, continues to plague children across the world, particularly in low and middle-income countries (LMICs). The situation has worsened alongside the SARS-CoV-2 pandemic because of major systemic disruptions to food supply, healthcare, and employment. Large-scale food fortification (LSFF) is a potential strategy for improving micronutrient intakes through the addition of vitamins and minerals to staple foods and improving the nutritional status of populations at large. Current evidence unquestionably supports the use of LSFF to improve micronutrient status. Evidence syntheses have also demonstrated impact on some functional outcomes, including anemia, wasting, underweight, and neural tube defects, that underpin poor health and development. Importantly, many of these effects have also been reflected in effectiveness studies that examine LSFF in real-world situations as opposed to under-controlled environments. However, programmatic challenges must be addressed in LMICs in order for LSFF efforts to reach their full potential. LSFF is an important strategy that has the potential to improve the health and nutrition of entire populations of vulnerable children. Now more than ever, existing programs should be strengthened and new programs implemented in areas with widespread undernutrition and micronutrient deficiencies.

Addressing the Fortification Quality Gap: A Proposed Way Forward.

Large-scale food fortification is an effective, sustainable, and scalable intervention to address vitamin and mineral deficiencies, however, pressing gaps exist globally around ensuring the quality of fortified foods. This paper summarizes the global challenges and gaps faced in monitoring the quality of fortified foods, the guidance produced in response to these challenges, where we are today in terms of effective implementation, and what approaches and opportunities may be usefully applied to enhance the quality of fortified foods moving forward.

Micronutrient Fortification of Commercially Available Biscuits Is Predicted to Have Minimal Impact on Prevalence of Inadequate Micronutrient Intakes: Modeling of National Dietary Data From Cameroon.

ABSTRACTBackgroundVoluntarily fortified snack products are increasingly available but are not necessarily formulated to meet known dietary nutrient gaps, so potential impacts on population micronutrient intake adequacy are uncertain.ObjectivesWe modeled the impacts of hypothetical micronutrient-fortified biscuits on inadequate micronutrient intake in children and women of reproductive age (WRA) in Cameroon.MethodsIn a nationally representative survey stratified by macro-region (North, South, and Yaoundé/Douala), 24-h dietary recall data were collected from 883 children aged 12–59 mo and from 912 WRA. We estimated usual nutrient intake by the National Cancer Institute method for vitamin A, folate, vitamin B-12, zinc, and iron. We simulated the impact of biscuit fortification on prevalence of micronutrient intake below the estimated average requirement, given observed biscuit consumption, in the presence and absence of large-scale food fortification (LSFF) programs.ResultsBiscuit consumption in the prior 24-h by children and WRA, respectively, ranged from 4.5% and 1.5% in the South, to 20.7% and 5.9% in Yaoundé/Douala. In the absence of LSFF programs, biscuits fortified with retinol (600 μg/100 g), folic acid (300 μg/100 g), and zinc (8 mg/100 g) were predicted to reduce the prevalence of inadequacy among children by 10.3 ± 4.4, 13.2 ± 4.2, and 12.0 ± 6.1 percentage points, respectively, in Yaoundé/Douala. However, when existing vitamin A–fortified oil, and folic acid–fortified and zinc-fortified wheat flour programs were considered, the additional impacts of fortified biscuits were reduced substantially. Micronutrient-fortified biscuits were predicted to have minimal impact on dietary inadequacy in WRA, with or without LSFF programs.ConclusionsGiven observed patterns of biscuit consumption in Cameroon, biscuit fortification is unlikely to reduce dietary inadequacy of studied micronutrients, except possibly for selected nutrients in children in urban areas in the absence of LSFF programs. As voluntary fortification becomes increasingly common, modeling studies could help guide efforts to ensure that fortified products align with public health goals.

Assessing the Coverage of Biofortified Foods: Development and Testing of Methods and Indicators in Musanze, Rwanda.

ABSTRACTBackgroundBiofortification of staple crops has the potential to increase nutrient intakes and improve health outcomes. Despite program data on the number of farming households reached with and growing biofortified crops, information on the coverage of biofortified foods in the general population is often lacking. Such information is needed to ascertain potential for impact and identify bottlenecks to parts of the impact pathway.ObjectivesWe aimed to develop and test methods and indicators for assessing household coverage of biofortified foods.MethodsTo assess biofortification programs, 5 indicators of population-wide household coverage were developed, building on approaches previously used to assess large-scale food fortification programs. These were 1) consumption of the food; 2) awareness of the biofortified food; 3) availability of the biofortified food; 4) consumption of the biofortified food (ever); and 5) consumption of the biofortified food (current). To ensure that the indicators are applicable to different settings they were tested in a cross-sectional household-based cluster survey in rural and peri-urban areas in Musanze District, Rwanda where planting materials for iron-biofortified beans (IBs) and orange-fleshed sweet potatoes (OFSPs) were delivered.ResultsAmong the 242 households surveyed, consumption of beans and sweet potatoes was 99.2% and 96.3%, respectively. Awareness of IBs or OFSPs was 65.7% and 48.8%, and availability was 23.6% and 10.7%, respectively. Overall, 15.3% and 10.7% of households reported ever consuming IBs and OFSPs, and 10.4% and 2.1% of households were currently consuming these foods, respectively. The major bottlenecks to coverage of biofortified foods were awareness and availability.ConclusionsThese methods and indicators fill a gap in the availability of tools to assess coverage of biofortified foods, and the results of the survey highlight their utility for identifying bottlenecks. Further testing is warranted to confirm the generalizability of the coverage indicators and inform their operationalization when deployed in different settings.

Assessing the Coverage of Biofortified Foods: Development and Testing of Methods and Indicators in Musanze, Rwanda

Abstract Objectives Biofortification is a promising approach to increase micronutrient intakes, especially among populations that are hard to reach with other interventions. Information on the coverage of biofortified foods is needed to ascertain potential for impact, understand program performance, and identify bottlenecks. In this study, we aimed to develop and test methods and indicators for assessing household coverage of biofortified foods. Methods We developed five recall-based indicators of household coverage to assess biofortification programs building on approaches previously used to assess targeted and large-scale food fortification programs. These were: 1) consumption of the food; 2) awareness of the biofortified food; 3) availability of the biofortified food; 4) consumption of the biofortified food (ever); and 5) consumption of the biofortified food (current). We tested these indicators in a cross-sectional, cluster, household survey in 20 rural and five peri-urban areas in Musanze, Rwanda where two biofortification programs, i.e., biofortified beans and orange fleshed sweet potatoes (OFSP), were implemented. Results Among the 242 households surveyed, consumption of beans and sweet potatoes was high (99% and 96%, respectively) while awareness of biofortified beans or OFSP was 66% and 49%, respectively, and availability was 24% and 11%, respectively. Overall, 15% and 11% of households had ever consumed biofortified beans and OFSP, respectively, and 10% and 2% of households were currently consuming them, respectively. The major bottlenecks to coverage were awareness and availability of the biofortified foods. Conclusions The proposed methods and indicators fill a gap in the availability of tools to assess biofortification program coverage and the results of the survey highlight their utility for assessing program performance and identifying bottlenecks. Further testing is warranted to confirm the generalizability of the coverage indicators and inform their operationalization when deployed in different contexts. Funding Sources Bill & Melinda Gates Foundation.

A Framework for Evidence-Based Decision Making in Large-Scale Food Fortification Programs

Abstract Objectives The use of evidence on program performance and potential for impact for decision making in food fortification programs is limited and often done in isolation from other micronutrient interventions. We present a framework for fortification stakeholders responsible for making program recommendations and decisions to facilitate and document evidence-based decision making. Methods First, we reviewed the literature to define the key decision makers and decisions necessary for effective fortification program design and delivery, informed by a clear impact pathway. Then we classified decisions by domain, identified data sources and criteria for their assessment, and adapted the GRADE Evidence to Decision framework to summarize the results. Finally, we considered how the framework would apply to different country programs to test its utility. Results Policymakers, particularly government ministries, and the food producers themselves are the most important decision makers in a fortification program, while technical support agencies, donor agencies, and the research community play important roles in translating data and evidence into contextualized recommendations that meet the needs of different decision makers. The main fortification decision types were classified into five domains across the impact pathway: 1) program design (need, food vehicle(s)); 2) program delivery (compliance, quality, coverage); 3) program impact (nutrient intake and status); 4) overlapping micronutrient interventions and/or under-served populations; and 5) decisions to continue or stop programs. Important criteria for the assessment of each decision type included priority, benefits/risks, equity, acceptability, and feasibility among others. Country examples illustrated the importance of coordinating decision-making in the context of overlapping micronutrient interventions to ensure continued safety and impact over time. Conclusions This framework is a practical tool to enable evidence-based decision making by fortification stakeholders. Using evidence in a systematic and transparent way can enable more effective program design, delivery, and ultimately health impacts. Funding Sources Bill & Melinda Gates Foundation.

Food Fortification: The Level of Awareness among Kenyan Consumers.

More than half of the morbidity and mortality cases among children in Kenya are as a result of micronutrient deficiencies (MNDs). Food fortification is considered by the Government of Kenya as a feasible strategy for addressing MNDs. Worldwide, fortification has been proven to be effective since it does not require any change in dietary habits. Success of large-scale food fortification however may depend on consumer awareness of the fortification benefits. A cross-sectional study was conducted in 13 counties to collect information on fortification awareness using structured questionnaires. 1435 respondents were selected using the Lot Quality Assurance Sampling method. Data were analyzed using Stata version 14.0 and statistical significance p < 0.05. The study participants were described using descriptive statistics. The association of sociodemographic characteristics and awareness of fortification was performed using binary logistic regression analysis. The median age of the study participants was 35 years. Only 28% of the respondents were aware of the term “fortification.” Of the respondents, about 27% heard of food fortification through radio. Vernacular radio emerged as the most preferred channel for communicating fortification information among 24.9% of the respondents. Although awareness of vitamins (32%) and minerals (1.5%) was limited, most (76%) respondents reported of existence of health risks for lacking micronutrients. Awareness of food fortification was significantly associated with respondents' occupation (p < 0.001), household size (p=0.012), education levels (p < 0.001), and age (p=0.025). There is need for a wider use of broadcast media sources to modify information and education materials to promote fortification awareness among Kenyan consumers.

The Unfinished Agenda for Food Fortification in Low- and Middle-Income Countries: Quantifying Progress, Gaps and Potential Opportunities

Large-scale food fortification (LSFF) is a cost-effective intervention that is widely implemented, but there is scope to further increase its potential. To identify gaps and opportunities, we first accessed the Global Fortification Data Exchange (GFDx) to identify countries that could benefit from new fortification programs. Second, we aggregated Fortification Assessment Coverage Toolkit (FACT) survey data from 16 countries to ascertain LSFF coverage and gaps therein. Third, we extended our narrative review to assess current innovations. We identified 84 countries as good candidates for new LSFF programs. FACT data revealed that the potential of oil/ghee and salt fortification is not being met due mainly to low coverage of adequately fortified foods (quality). Wheat, rice and maize flour fortification have similar quality issues combined with lower coverage of the fortifiable food at population-level (<50%). A four-pronged strategy is needed to meet the unfinished agenda: first, establish new LSFF programs where warranted; second, systems innovations informed by implementation research to address coverage and quality gaps; third, advocacy to form new partnerships and resources, particularly with the private sector; and finally, exploration of new fortificants and vehicles (e.g. bouillon cubes; salt fortified with multiple nutrients) and other innovations that can address existing challenges.

Improved micronutrient status and health outcomes in low- and middle-income countries following large-scale fortification: evidence from a systematic review and meta-analysis

ABSTRACTBackgroundMicronutrient malnutrition is highly prevalent in low- and middle-income countries (LMICs) and disproportionately affects women and children. Although the effectiveness of large-scale food fortification (LSFF) of staple foods to prevent micronutrient deficiencies in high-income settings has been demonstrated, its effectiveness in LMICs is less well characterized. This is important as food consumption patterns, potential food vehicles, and therefore potential for impact may vary substantially in these contexts.ObjectivesThe aim of this study was to determine the real-world impact of LSFF with key micronutrients (vitamin A, iodine, iron, folic acid) on improving micronutrient status and functional health outcomes in LMICs.MethodsAll applicable published/unpublished evidence was systematically retrieved and analyzed. Studies were not restricted by age or sex. Meta-analyses were performed for quantitative outcomes and results were presented as summary RRs, ORs, or standardized mean differences (SMDs) with 95% CIs.ResultsLSFF increased serum micronutrient concentrations in several populations and demonstrated a positive impact on functional outcomes, including a 34% reduction in anemia (RR: 0.66; 95% CI: 0.59, 0.74), a 74% reduction in the odds of goiter (OR: 0.26; 95% CI: 0.16, 0.43), and a 41% reduction in the odds of neural tube defects (OR: 0.59; 95% CI: 0.49, 0.70). Additionally, we found that LSFF with vitamin A could protect nearly 3 million children per year from vitamin A deficiency. We noted an age-specific effect of fortification, with women (aged >18 y) attaining greater benefit than children, who may consume smaller quantities of fortified staple foods. Several programmatic/implementation factors were also reviewed that may facilitate or limit program potential.ConclusionsMeasurable improvements in the micronutrient and health status of women and children are possible with LSFF. However, context and implementation factors are important when assessing programmatic sustainability and impact, and data on these are quite limited in LMIC studies.

Large-Scale Food Fortification and Biofortification in Low- and Middle-Income Countries: A Review of Programs, Trends, Challenges, and Evidence Gaps.

BackgroundFood fortification and biofortification are well-established strategies to address micronutrient deficiencies in vulnerable populations. However, the effectiveness of fortification programs is not only determined by the biological efficacy of the fortified foods but also by effective and sustainable implementation, which requires continual monitoring, quality assurance and control, and corrective measures to ensure high compliance.ObjectiveTo provide an overview of efficacy, effectiveness, economics of food fortification and biofortification, and status of and challenges faced by large-scale food fortification programs in low- and middle-income countries (LMIC).MethodsA literature review of PubMed publications in English from 2000 to 2017, as well as gray literature, targeting nongovernmental organizations whose work focuses on this topic, complemented by national reports and a “snowball” process of citation searching. The article describes remaining technical challenges, barriers, and evidence gap and prioritizes recommendations and next steps to further accelerate progress and potential of impact.ResultsThe review identifies and highlights essential components of successful programs. It also points out issues that determine poor program performance, including lack of adequate monitoring and enforcement and poor compliance with standards by industry.ConclusionsIn the last 17 years, large-scale food fortification initiatives have been reaching increasingly larger segments of populations in LMIC. Large-scale food fortification and biofortification should be part of other nutrition-specific and nutrition-sensitive efforts to prevent and control micronutrient deficiencies. There are remaining technical and food system challenges, especially in relation to improving coverage and quality of delivery and measuring progress of national programs.

A public health approach for preventing neural tube defects: folic acid fortification and beyond.

In this paper we review the evidence basis for prevention of folic acid-sensitive neural tube defects (NTDs) through public health interventions in women of reproductive age (WRA), the proven vehicles for delivery of folic acid, and what is needed to effectively scale these, and provide a snapshot of potential innovations that require future research. Our primary focus is on the global situation affecting large-scale food fortification (LSFF) with folic acid, in particular the fortification of wheat flour and maize meal. Our overarching conclusion is that folic acid fortification is an evidence-based intervention that reduces the prevalence of NTDs, and that LSFF with folic acid is underutilized. Thus, food fortification with folic acid should be a component of most national public health strategies, in particular where folate status is insufficient and a fortifiable food vehicle, processed by a centralized industry, is consumed regularly by WRA. The evidence shows that there is still much work needed (1) to build the enabling environment and expand programs where there is currently no legislation, (2) to improve the low quality of delivery of existing programs, and (3) to measure and sustain programs by generating new coverage data and demonstrating evidence of impact in low- and middle-income countries.

PROTOCOL: Large-scale food fortification (LSFF) efforts for improving health outcomes in low- and middle-income countries: a systematic review.

PROTOCOL: Large-scale food fortification (LSFF) efforts for improving health outcomes in low- and middle-income countries: a systematic review.

Iron, Zinc, Folate, and Vitamin B-12 Status Increased among Women and Children in Yaoundé and Douala, Cameroon, 1 Year after Introducing Fortified Wheat Flour

Background: Few data are available on the effectiveness of large-scale food fortification programs.Objective: We assessed the impact of mandatory wheat flour fortification on micronutrient status in Yaoundé and Douala, Cameroon.Methods: We conducted representative surveys 2 y before and 1 y after the introduction of fortified wheat flour. In each survey, 10 households were selected within each of the same 30 clusters (n = ∼300 households). Indicators of inflammation, malaria, anemia, and micronutrient status [plasma ferritin, soluble transferrin receptor (sTfR), zinc, folate, and vitamin B-12] were assessed among women aged 15–49 y and children 12–59 mo of age.Results: Wheat flour was consumed in the past 7 d by ≥90% of participants. Postfortification, mean total iron and zinc concentrations of flour samples were 46.2 and 73.6 mg/kg (target added amounts were 60 and 95 mg/kg, respectively). Maternal anemia prevalence was significantly lower postfortification (46.7% compared with 39.1%; adjusted P = 0.01), but mean hemoglobin concentrations and child anemia prevalence did not differ. For both women and children postfortification, mean plasma concentrations were greater for ferritin and lower for sTfR after adjustments for potential confounders. Mean plasma zinc concentrations were greater postfortification and the prevalence of low plasma zinc concentration in women after fortification (21%) was lower than before fortification (39%, P < 0.001); likewise in children, the prevalence postfortification (28%) was lower than prefortification (47%, P < 0.001). Mean plasma total folate concentrations were ∼250% greater postfortification among women (47 compared with 15 nmol/L) and children (56 compared with 20 nmol/L), and the prevalence of low plasma folate values was <1% after fortification in both population subgroups. In a nonrepresentative subset of plasma samples, folic acid was detected in 77% of women (73% of those fasting) and 93% of children. Mean plasma and breast-milk vitamin B-12 concentrations were >50% greater postfortification.Conclusion: Although the pre-post survey design limits causal inference, iron, zinc, folate, and vitamin B-12 status increased among women and children in urban Cameroon after mandatory wheat flour fortification.