Industry Self-Regulation of Food Fortification Compliance: Piloting the Micronutrient Fortification Index in Nigeria.

Sustaining large-scale and good-quality food fortification requires strategies that incentivize food processors to invest in and consistently meet national food fortification standards where they exist. A standardized Micronutrient Fortification Index (MFI) piloted in Nigeria has provided a ranking of fortified branded products for each participating company, based on a score aggregating the effectiveness and efficiency of the company's systems and levels of product fortification. The MFI has demonstrated the significance of brands as a focal point for investment and industry accountability in food fortification and the power of harnessing the competitive nature of businesses to drive their food fortification performance. The initiative started with a pilot consisting of well-known brands of 4 companies and has since expanded participation to 15 companies, representing 31 brands, having completed the first entire ranking cycle. The publicly listed brands on the Index now cover approximately 80% of the flour milling market, 40% of the edible oils market, and 88% of the sugar market in Nigeria, reaching an estimated 134 million people in the country in 2022 according to analysis by TechnoServe Supporting African Processors of Fortified Foods (SAPFF) program in Nigeria. The data inputs are made through company-owned digital portals, and the results are published on a secure, web-based public portal which also serves as a gateway for stakeholders to access related information on micronutrient fortification and food quality (https://technoserve-mfi.web.app/). The ultimate aim of the MFI is to serve as a leverage for private sector efforts to both digitalize quality assurance and business processes linked to industrial automation and to harness their competitiveness through voluntary participation in the Index to drive improved food fortification performance based on industry best practices and quality benchmarks.

Coverage of Nutrition Interventions Intended for Infants and Young Children Varies Greatly across Programs: Results from Coverage Surveys in 5 Countries.

Background: The efficacy of a number of interventions that include fortified complementary foods (FCFs) or other products to improve infant and young child feeding (IYCF) is well established. Programs that provide such products free or at a subsidized price are implemented in many countries around the world. Demonstrating the impact at scale of these programs has been challenging, and rigorous information on coverage and utilization is lacking.Objective: The objective of this article is to review key findings from 11 coverage surveys of IYCF programs distributing or selling FCFs or micronutrient powders in 5 countries.Methods: Programs were implemented in Ghana, Cote d'Ivoire, India, Bangladesh, and Vietnam. Surveys were implemented at different stages of program implementation between 2013 and 2015. The Fortification Assessment Coverage Toolkit (FACT) was developed to assess 3 levels of coverage (message: awareness of the product; contact: use of the product ≥1 time; and effective: regular use aligned with program-specific goals), as well as barriers and factors that facilitate coverage. Analyses included the coverage estimates, as well as an assessment of equity of coverage between the poor and nonpoor, and between those with poor and adequate child feeding practices.Results: Coverage varied greatly between countries and program models. Message coverage ranged from 29.0% to 99.7%, contact coverage from 22.6% to 94.4%, and effective coverage from 0.8% to 88.3%. Beyond creating awareness, programs that achieved high coverage were those with effective mechanisms in place to overcome barriers for both supply and demand.Conclusions: Variability in coverage was likely due to the program design, delivery model, quality of implementation, and product type. Measuring program coverage and understanding its determinants is essential for program improvement and to estimate the potential for impact of programs at scale. Use of the FACT can help overcome this evidence gap.

A Delivery Model for Home Fortification of Complementary Foods with Micronutrient Powders: Innovation in the Context of Vietnamese Health System Strengthening.

Adding micronutrient powders (MNP) to complementary foods at the point of preparation (home fortification) can improve micronutrient status of young children. Ensuring sustained access to MNPs at scale, however, remains challenging in many countries. The Global Alliance for Improved Nutrition (GAIN) partnered with the National Institute of Nutrition (NIN) in Vietnam to pioneer the distribution of a locally-produced MNP, provided for sale through the public health system with counseling on optimal infant and young child feeding practices by trained health workers. Different packaging options were available to adapt to caregivers' disposable income. During the six-month pilot, 1.5 million sachets were sold through 337 health centers across four provinces, targeting children 6-59 months of age. Sales were routinely monitored, and a cross-sectional survey in 32 communes for caregivers (n = 962) and health staff (n = 120) assessed MNP coverage and compliance, five months after the start of distribution. A total of 404 caregivers among the 962 caregivers surveyed (i.e., 42%) had visited the health center in the past year. Among them, 290 caregivers had heard about the product and a total of 217caregivers had given the MNP to their child at least once, representing a conversion rate from product awareness to product trial of 74.8%. The effective coverage (i.e., consumption of ≥3 sachets/child/week) was 11.5% among the total surveyed caregivers and reached 27.3% amongst caregivers who visited health centers in the previous month. The MNP purchase trends showed that the number of sachets bought by caregivers was positively correlated with the wealth index. The pilot showed that providing MNPs for sale in packs of various quantities, combined with infant and young child feeding (IYCF) counseling at the health center, is effective for groups accessing the health system.

A review of vitamin D fortification: implications for nutrition programming in Southeast Asia.

BACKGROUND: Vitamin D is vital for bone health and has important roles in nonskeletal health and organ function. Most vitamin D is generated in the body by exposure to sunlight, with limited amounts added by the diet. Despite the presence of regular sunshine in Southeast Asia, vitamin D deficiency or insufficiency is being found there more commonly, primarily due to reduction of sunlight exposure as a result of lifestyle changes. Some of these lifestyle changes are unlikely to be reversed, and foods naturally containing vitamin D are not widely consumed, so fortification of foods with vitamin D may raise vitamin D status. METHODS: The literature database was searched for studies of vitamin D fortification, and we estimated potential vitamin D intakes from fortified vegetable oil. RESULTS: Almost all of the studies showed that circulating vitamin D (25-hydroxyvitamin D [(25OHD]) increased in a dose-dependent manner with increased intake of vitamin D-fortified foods. However, in a number of studies the additional intake was insufficient to increase vitamin D levels to 50 nmol/L. Vegetable oil fortified with vitamin D at a level of 10 microg/100 g could provide 3.9% to 21% of the Institute of Medicine Estimated Average Requirement (EAR) of vitamin D for adults in Southeast Asia. CONCLUSIONS: Fortification of widely consumed foods, such as edible oil, with vitamin D could contribute to improved vitamin D status in Southeast Asian countries. Intake modeling studies should be conducted to calculate the resulting additional intakes, and fortification of additional foods should be considered. More nationally representative studies of vitamin D status in the region are urgently needed.

The focused ethnographic study 'assessing the behavioral and local market environment for improving the diets of infants and young children 6 to 23 months old' and its use in three countries.

The concept of a focused ethnographic study (FES) emerged as a new methodology to answer specific sets of questions that are required by agencies, policymakers, programme planners or by project implementation teams in order to make decisions about future actions with respect to social, public health or nutrition interventions, and for public-private partnership activities. This paper describes the FES on complementary feeding that was commissioned by the Global Alliance for Improved Nutrition and highlights findings from studies conducted in three very different country contexts (Ghana, South Africa and Afghanistan) burdened by high levels of malnutrition in older infants and young children (IYC). The findings are analysed from the perspective of decision-making for future interventions. In Ghana, a primary finding was that in urban areas the fortified, but not instant cereal, which was being proposed, would not be an appropriate intervention, given the complex balancing of time, costs and health concerns of caregivers. In both urban and rural South Africa, home fortification products such as micronutrient powders and small quantity, lipid-based nutrient supplements (LNS) are potentially feasible interventions, and would require thoughtful behaviour change communication programmes to support their adoption. Among the important results for future decision-making for interventions in Afghanistan are the findings that there is little cultural recognition of the concept of special foods for infants, and that within households food procurement for IYC are in the hands of men, whereas food preparation and feeding are women's responsibilities.

Fortifying complementary foods with NaFeEDTA--considerations for developing countries.

As a highly bioavailable iron compound, sodium iron (iii) ethylenediaminetetraacetate (NaFeEDTA) has been recommended as a food additive for fortification. The amount of a food additive that can be ingested daily over a lifetime without appreciable health risk is termed the acceptable daily intake (ADI). The ADI for NaFeEDTA is based on body weight. For complementary foods and food supplements for infants and young children in low-income countries, where prevalence of underweight is high yet nutrient needs are also high, it is not clear which doses might be appropriate. The objective is to calculate the dosage of NaFeEDTA for fortifying complementary foods assuming different population prevalences of underweight. Mathematical models were used to simulate the dosage of NaFeEDTA for 6- to 8-month-old infants under different prevalences of underweight ranging from 5% to 40%. In order to keep NaFeEDTA intake below the ADI for ethylenediaminetetraacetate (EDTA) recommended by the Joint Food and Agriculture Organization (FAO)/World Health Organization (WHO) Expert Committee on Food Additives for 95% of 6- to 8-month-old infants, the daily iron dose from NaFeEDTA in fortified complementary foods should be set between 2.2 mg and 1.8 mg in countries with a prevalence of underweight among 6- to 8-month-old infants between 5% and 40%, respectively. If 2 mg of iron is given to all 6- to 8-month-old infants, the percentage exceeding the ADI for EDTA would be <10% for populations with <30% of children who are underweight, which is the case for many countries. In conclusion, 2 mg of iron from NaFeEDTA could be used for fortifying one daily serving of complementary food to ensure EDTA levels are below the ADI for infants 6-8 months of age. An additional source of iron (such as ferrous sulfate) should be included to increase the iron dose to desired fortification levels.