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

2. 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

3. 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

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

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

6. 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.

7. 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

8. 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

9. 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

10. 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

11. 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

12. Current Activities: Middle East
Countries fortifying as of July 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

13. 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

14. 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

15. 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?

16. 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

17. 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

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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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?

26. 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