Quentin Johnson, Fortification Consultant Presentation to NFA Georgia July, 2005 International Activities on Food Fortification Quentin Johnson, Fortification Consultant GAIN

Successful Fortification Programmes 1920’s Switzerland Salt Iodization 1930’s N. Europe Vitamin D in dairy 1930’s Denmark Vitamin A in margarine 1940’s N America Vit B, Iron in flour 1974 Guatemala Vitamin A in sugar 1992 Universal Salt Iodization

Successful Fortification Programmes 1996 N America Folic Acid in Flour 1996 Venezuela Vit A,B’s Iron in Flour 1998 Philippines Vitamin A in flour 1999 Zambia Vitamin A in sugar 1999 Indonesia Iron Folic Acid Zinc in flour 1999 Egypt Iron in Biscuit flour 2000 Mexico Addition of Zinc to fortified flour 2002 Jordan, Kuwait, Qatar Iron Folic Acid 2002 South Africa Wheat and Maize flour 2002 CARK Region

Conditions For Successful Fortification Programs Political Support Industry Support Adequate Legislation Consumer Acceptance No Cultural or other Objection Availability of Micronutrients Economically sustainable

Which countries fortify flour with iron? In Place (31 countries) In Process (20plus countries) Note: India project basis only Sources: MI, UNICEF & WHO

Micronutrient Fortification of Cereal Flours: An Important Global Strategy USA/Canada:mandatory and ongoing since 1940s. Latin America: 14 out of 24 countries have mandatory fortification. Significant impact in Chile/Venezuela. Asia: 35% of flour in Philippines is fortified;All flour in Indonesia fortified. Africa:South Africa ready to launch national corn meal fortification.Permitted in Kenya/Uganda. Middle East and North Africa: Mandatory in 6 countries. Partial fortification in Egypt/Morocco.

Fortification Activities around the World: Current Status SUB-SAHARAN AFRICA Cereal (Maize, Wheat) Fortification with multiple micronutrients Voluntary fortification in Angola, Congo, Kenya, Lesotho, Malawi, Tanzania, Uganda, Mandatory fortification in Nigeria for wheat flour South Africa for wheat flour maize meal Mandatory fortification of Sugar in Zambia

Current Activities: ASIA India - Projects in West Bengal small scale fortification, bioavailability studies, some private roller mills fortifying flour Bangladesh - Fortification of flour from donated wheat USAID with WFP Nepal - National fortification of wheat flour proposed – start date October 2005

Current Activities: Asia Afghanistan - WFP flour fortified with assistance from WHO MI – SSF in Kabul and Badakhshan Indonesia - Mandatory Fortification of wheat flour Pakistan - Chakki mill and Roller mill fortification projects supported by GAIN, MI WHO Thailand - Instant Noodle fortification of spice packet with Iodine, Iron and Vitamin A

Current Activities: ASIA Central Asia - Development of Regional standard for flour fortification in 6 CARK nations with assistance from ADB China - Western China flour fortification with Fe Na EDTA South and South East Asia - ADB RETA project for China, India, Indonesia, Pakistan, Thailand and Vietnam - flour and vegetable oil

Current Activities: Middle East Flour Regional Workshops- Iran 1995, Oman 1996, Beirut 1998 International Agency Partners MI, WHO. UNICEF Regional Standard recommended by WHO *60 ppm Iron, electrolytic or 30 ppm as FeSO4 1.5 ppm Folic Acid Proposed fortification standard for Georgia 60 ppm Electrolytic iron and Folic Acid

Current Activities: Middle East Countries fortifying as of July 2005 - Bahrain, Jordan, Kuwait, Oman, Qatar, Saudi Arabia, Egypt (school children biscuit flour with Iron) Projects underway - Egypt, Iran, Syria Morocco - National programme to start November 2005 Legislation - Libya (flour) and Yemen (flour and oil) GCC - Adoption of Fortified Wheat flour standard UAE - Voluntary fortification with Iron and Folic Acid

Common Challenges Cost of fortification - can represent more than profit margin for mills in Jordan or 10% increase in SSF milling fee Lack of dietary diversification - presence of natural inhibitors ie phytates and tannins Disease and Poor Health - AIDS, Malaria, Intestinal parasites Low Utilization rates in Large Mills - Bangladesh, India, Pakistan

Common Challenges Fortification form of birth control, Religious and Cultural objections to adding something to foods Consumption of inhibitors i.e. tea Regulatory barriers i.e. Pure Food Act Lack of Technology

Common Challenges: Questions raised Will the product change? Will the playing field be level? Will the price increase? Are we being manipulated by foreign interests? Will the fortificant be bio-available? Is it safe and can it be toxic? Will industry be able to assure quality? Are these chemicals natural? Is this related to GMF?

Addressing Challenges Disease and Public Health Concurrent programmes of fortification and Public Health to control Malaria and Intestinal problems AIDS significant issue in Africa and now in Asia Misinformation Strong IEC and Social Marketing Campaigns

Addressing challenges: Examples Morocco - Millers pay for premix and feeders Government pays for Social Marketing and advertising campaigns Jordan - MOH included premix cost as budget line item. Feeder costs covered by WHO/MI/UNICEF fund Bahrain - Premix cost covered by MOH and Ministry of Commerce

Addressing Challenges:Examples Qatar - Inspection Fee for wheat imports eliminated to pay for premix and feeders Moldova - 0.25% Customs Service Fee identified to be eliminated to cover cost of premix

Addressing Challenges:Examples Fortification costs are being covered by adjustment of existing government fees and reduction in import duties for equipment and premix Wheat price variations more significant than cost of fortifications: (Note due to drought in North America wheat prices in 2002 up by 35-50%) All parts of national budgets to be looked at for potential sources of funding

Global Alliance for Improved Nutrition, GAIN Sponsored by Bill and Melinda Gates Foundation, CIDA, USAID Assistance Grants for National Fortification Programmes 15 Countries received grants to date including Burkina Faso, China, Cote d’Ivoire, Dominican Republic, Ghana, Mali, Morocco, Nigeria, Pakistan, South Africa

GAIN Proposal Requirements National Fortification Alliance – must be multisectoral partnership - Industry, Government, Civil Society, NGOs National programme must be sustainable once started and after GAIN funding stops GAIN funds for only 3 years but proposal 5 years Proposal: RFP documents and budget document Maximum from GAIN $3 million

GAIN Proposal Documents RFP Document must cover overall objective and 5 Components Production and Distribution Safety and Quality of Fortified food Social Marketing and Communications Monitoring, Evaluation and Impact Programme Management RFP Budget Covers Costs Sources of funding

GAIN Grants Successful Proposals Strong Political Support Demonstrated strong partnerships between government, industry and civil society Demonstrated commitment to long term sustainability Balanced funding sources from GAIN, government (in-kind), civil society, and industry Realistic

Flour Fortification: The importance of engaging all Stakeholders Wheat Export Boards Commodity Companies Milling Associations Milling Companies Food Companies & Bakers Governments Regional Bodies Trade Organizations Consumer Groups Consumers MI, CDC UN Organizations GAIN Other International Organizations

What are the costs for the premixes? Fe 60 ppm: $.33/MT FE + Folic : $.50/MT FE, Folic Acid + B Vitamins: $1.10/MT* Multi-Nutrient Mix w/Vitamin A $2.35/MT For 100 kg Annual Cost: $0.03- $.24/pp/yr * 0.5% of flour price Relative Premix Costs South Africa Source: Jack Bagriansky What are the costs for the premixes?

Universal flour fortification could make a very large impact Wheat & Maize Flour Map of countries shows the potential contribution to Iron RDI from wheat & maize flour consumed (gm/day) if 30 ppm of iron were absorbed from the flour % US RDI <25% 25-49% 50-74% >75% Data not presented Data not presented Data source: FAO 1997 Universal flour fortification could make a very large impact