Assessing alternative industrial fortification portfolios: a Bangladesh case study.

BACKGROUND: Approximately 1.2 million disability-adjusted life years (DALYs) are lost annually in Bangladesh due to deficiencies of vitamin A, iron, and zinc. OBJECTIVE: To provide evidence on the coverage, costs, and cost-effectiveness of alternative fortification interventions to inform nutrition policy-making in Bangladesh. METHODS: Combining the 2005 Bangladesh Household Income and Expenditure Survey with a Bangladesh food composition table, apparent intakes of energy, vitamin A, iron, and zinc, and the coverage and apparent consumption levels of fortifiable vegetable oil and wheat flour are estimated. Assuming that fortification levels are those established in official regulations, the costs and cost-effectiveness of the two vehicles are assessed independently and as a two-vehicle portfolio. RESULTS: Vegetable oil has a coverage rate of 76% and is estimated to reduce the prevalence of inadequate vitamin A intake from 83% to 64%. The coverage of wheat flour is high (65%), but the small quantities consumed result in small reductions in the prevalence of inadequate intakes: 1.5 percentage points for iron, less than 1 for zinc, and 2 for vitamin A, while reducing average Estimated Average Requirement (EAR) gaps by 8%, 9%, and 15%, respectively. The most cost-effective 10-micronutrient wheat flour formulation costs US $1.91 million annually, saving 129,212 DALYs at a unit cost of US $14.75. Fortifying vegetable oil would cost US $1.27 million annually, saving 406,877 DALYs at an average cost of US $3.25. Sensitivity analyses explore various permutations of the wheat flour formulation. Divisional variations in coverage, cost, and impact are examined. CONCLUSIONS: Vegetable oil fortification is the most cost-effective of the three portfolios analyzed, but all three are very cost-effective options for Bangladesh.

Stability and retention of micronutrients in fortified rice prepared using different cooking methods.

Fortified rice holds great potential for bringing essential micronutrients to a large part of the world population. However, it is unknown whether differences in cooking methods or in production of rice premix affect the final amount of micronutrient consumed. This paper presents a study that quantified the losses of five different micronutrients (vitamin A, iron, zinc, folic acid, and vitamin B12) in fortified rice that was produced using three different techniques (hot extrusion, cold extrusion, and coating) during cooking and five different cooking methods (absorption method with or without soaking, washing before cooking, cooking in excess water, and frying rice before cooking). Fortified rice premix from six different producers (two for each technique) was mixed with normal rice in a 1:100 ratio. Each sample was prepared in triplicate, using the five different cooking methods, and retention of iron, zinc, vitamin A, vitamin B12, and folic acid was determined. It was found that the overall retention of iron, zinc, vitamin B12, and folic acid was between 75% and 100% and was unaffected by cooking method, while the retention of vitamin A was significantly affected by cooking method, with retention ranging from 0% (excess water) to 80% (soaking), depending on the cooking method and producer of the rice premix. No systematic differences between the different production methods were observed. We conclude that different cooking methods of rice as used in different regions of the world do not lead to a major loss of most micronutrients, with the exception of vitamin A. The factors involved in protecting vitamin A against losses during cooking need to be identified. All production techniques of rice premix yielded similar results, showing that coating is not inferior to extrusion techniques. Standard overages (50%) for vitamin B12 and folic acid are too high.

Rice fortification: a comparative analysis in mandated settings.

Legal mandates can play an important role in the success of rice fortification programs that involve the private sector. However, merely enacting mandatory legislation does not guarantee success; it requires a coordinated, multidimensional cross-sector effort that addresses stewardship, develops an appropriate rice fortification technology, enables sustainable production and distribution channels through a range of private-sector players, ensures quality, generates consumer demand, and monitors progress. Furthermore, economic sustainability must be built into the supply chain and distribution network to enable the program to outlast government administrations and/or time-limited funding. Hence, mandates can serve as valuable long-term enablers of cross-sector mobilization and collaboration and as catalysts of civil society engagement in and ownership of fortification programs. This paper compares the rice fortification experiences of Costa Rica and the Philippines--two countries with mandates, yet distinctly different industry landscapes. Costa Rica has achieved national success through strong government stewardship and active market development--key elements of success regardless of industry structure. With a comparatively more diffuse rice industry structure, the Philippines has also had success in limited geographies where key stakeholders have played an active role in market development. A comparative analysis provides lessons that may be relevant to other rice fortification programs.

Maize flour fortification in Africa: markets, feasibility, coverage, and costs.

The economic feasibility of maize flour and maize meal fortification in Kenya, Uganda, and Zambia is assessed using information about the maize milling industry, households' purchases and consumption levels of maize flour, and the incremental cost and estimated price impacts of fortification. Premix costs comprise the overwhelming share of incremental fortification costs and vary by 50% in Kenya and by more than 100% across the three countries. The estimated incremental cost of maize flour fortification per metric ton varies from $3.19 in Zambia to $4.41 in Uganda. Assuming all incremental costs are passed onto the consumer, fortification in Zambia would result in at most a 0.9% increase in the price of maize flour, and would increase annual outlays of the average maize flour-consuming household by 0.2%. The increases for Kenyans and Ugandans would be even less. Although the coverage of maize flour fortification is not likely to be as high as some advocates have predicted, fortification is economically feasible, and would reduce deficiencies of multiple micronutrients, which are significant public health problems in each of these countries.

The global, centralized approach of the GAIN Premix Facility has made oil fortification in Indonesia more affordable.

BACKGROUND: Access to high-grade micronutrients is a recurring challenge that often threatens the long-term sustainability of food fortification programs. OBJECTIVE: To assess the efficiency of the Global Alliance for Improved Nutrition (GAIN) Premix Facility in procuring quality, affordable vitamin A for fortification of edible oil in Indonesia. METHODS: A global approach to procurement of standard items was used by combining volumes across various demand streams in order to reduce the total cost of acquisition through economies of scale. The GAIN Premix Facility undertook a detailed analysis of vitamin A requirements across its existing customer base, which served as a basis for developing a reliable demand forecast. A consolidated, competitive tender was launched that resulted in the setting up of a long-term commercial agreement with the selected supplier to lock in the most competitive price for a given period of time. RESULTS: The direct benefit to oil manufacturers of fortifying with vitamin A is that the cost of fortification went down significantly compared with prices they would have been offered had they ordered vitamin A individually. In Indonesia, this consolidated procurement approach has allowed a 14.5% decrease in the unit price of vitamin A. CONCLUSIONS: The GAIN Premix Facility demonstrated its effectiveness in acting as a global procurement platform by aggregating demand across different customers and leveraging improved prices through increased volumes. Building on the success of this effort, the GAIN Premix Facility is replicating this global approach for procurement of other standard items being procured across fortification programs worldwide.

Assessing Zambia's industrial fortification options: getting beyond changes in prevalence and cost-effectiveness.

Background. Since fortification of sugar with vitamin A was mandated in 1998, Zambia's fortification program has not changed, while the country remains plagued by high rates ofmicronutrient deficiencies. Objective. To provide evidence-based fortification options with the hope of reinvigorating the Zambian fortification program. Methods. Zambia's 2006 Living Conditions Monitoring Survey is used to estimate the apparent intakes of vitamin A, iron, and zinc, as well as the apparent consumption levels and coverage of four fortification vehicles. Fourteen alternativefoodfortification portfolios are modeled, and their costs, impacts, average cost-effectiveness, and incremental cost-effectiveness are calculated using three alternative impact measures. Results. Alternative impact measures result in different rank orderings of the portfolios. The most cost-effective portfolio is vegetable oil, which has a cost per disability-adjusted life-year (DALY) saved ranging from 12% to 25% of that of sugar, depending on the impact measure used. The public health impact of fortified vegetable oil, however, is relatively modest. Additional criteria beyond cost-effectiveness are introduced and used to rank order the portfolios. The size of the public health impact, the total cost, and the incremental cost-effectiveness of phasing in multiple vehicle portfolios over time are analyzed. Conclusions. Assessing fortification portfolios by measuring changes in the prevalence of inadequate intakes underestimates impact. A more sensitive measure, which also takes into account change in the Estimated Average Requirement (EAR) gap, is provided by a dose-response-based approach to estimating the number ofDALYs saved. There exist highly cost-effective fortification intervention portfolios with substantial public health impacts and variable price tags that could help improve Zambians' nutrition status.

GAIN Premix Facility: an innovative approach for improving access to quality vitamin and mineral premix in fortification initiatives.

BACKGROUND: Vitamin and mineral premix is one of the most significant recurring input costs for large-scale food fortification programs. A number of barriers exist to procuring adequate quality premix, including accessing suppliers, volatile prices for premix, lack of quality assurance and monitoring of delivered products, and lack of funds to purchase premix. OBJECTIVE: To develop and test a model to procure premix through a transparent and efficient process in which an adequate level of quality is guaranteed and a financial mechanism is in place to support countries or specific target groups when there are insufficient resources to cover the cost of premix. METHODS: Efforts focused on premixes used to fortify flour, such as wheat or maize (iron, zinc, B vitamins, and vitamin A), edible oils (vitamins A and D), and other food vehicles, such as fortified complementary foods, complementary food supplements, and condiments. A premix procurement model was set up with three distinct components: a certification process that establishes industry-wide standards and guidelines for premix, a procurement facility that makes premix more accessible to countries and private industry engaged in fortification, and a credit facility mechanism that helps projects finance premix purchases. RESULTS: After three years of operation, 15 premix suppliers and 29 micronutrient manufacturers have been certified, and more than US$23 million worth of premix that met quality standards has been supplied in 34 countries in Africa, Central and Southern Asia, and Eastern Europe, reaching an estimated 242 million consumers. CONCLUSIONS: The Premix Facility demonstrated its effectiveness in ensuring access to high-quality premixes, therefore enabling the success of various fortification programs.