Addressing Micronutrient Malnutrition in Urban Settings

Abstract

Access to nutritious foods for those living in poor urban settings is often more of a problem than the availability of these foods. This chapter describes a proven and effective strategy to impact food quality in urban settings through the implementation of national, mandatory food fortification programs. By leveraging what large sectors of the urban population already have access to and are already consuming on a regular basis, no new delivery mechanisms are needed, limited behavior change is required, and no additional responsibilities are placed on the healthcare system. Based on Project Healthy Children’s experience assisting governments to design and implement national fortification programs, this chapter describes micronutrient malnutrition, particularly in the context of urban settings, and the various interventions that exist to address it. The chapter proceeds to discuss why fortification is a well-suited strategy for urban populations touching on new design and implementation opportunities that exist around small-scale fortification. Broad steps necessary to design a program and critical components needed to successfully implement in urban settings are outlined. Finally, the chapter concludes with important lessons learned from past programs in East Africa.

Appendices

Appendix: Macronutrients vs. Micronutrients

It was not until the 1980s that efforts to address malnutrition shifted from a focus solely on a lack of protein and calories (known as protein-energy or “macronutrient” malnutrition) to one focused on a lack of vitamins and minerals (known as “micronutrient” malnutrition) [5]. Macronutrients are carbohydrates, proteins, and fats. Micronutrients are essential vitamins and minerals, such as iron, folic acid, zinc, vitamin A, and iodine, required in only small amounts yet remain critical to the human body for proper health and development. The body cannot produce most micronutrients, so they must be obtained directly from the diet.

How Is Food Actually Fortified?

Although the process of adopting fortification differs for production facilities depending on the food being fortified and the current state of the facility, the major premise remains the same: 1) the food processor identifies required changes that must take place, which generally includes source and cost of needed equipment, source and cost of premix (i.e., blend of vitamins and minerals based on established national standards), and required process line alterations; and 2) the food processor establishes internal quality assurance and quality control measures that continually test the safety and efficacy of the premix and fortified product.

Step 1: Identification of equipment needs, premix, and process line changes. The introduction of fortification into a facility’s production line can happen, even if a plant is already operating. Fortunately, most modern facilities already have the equipment needed for fortification [70]. Dosifiers, used to accurately dispense the correct amount of premix, are often already used to add ascorbic acid and vitamin E for food preservation purposes. The same holds true in many cases for mixers, which are important in fortification to ensure the premix is mixed equally into the final product. Where this is not the case, it is a relatively straightforward process to add a dosifier and appropriate mixing devices. The establishment of quality assurance and quality control measures specific to fortification will be outlined in Step 2.

For facilities that do need to purchase new equipment, dosifier costs can range from $1,000–20,000, depending on the kind of dosifier chosen (i.e., volumetric, gravimetric, or loss-of-weight, in order of expense). Mixing units can range from $2,000–10,000. The cost of premix, where the bulk of fortification costs fall, will depend on the type and number of nutrients added and the amount of product that is produced. Rice fortification is the only process where the number of micronutrients added does not affect cost because of the comparatively high price of purchasing rice kernels for extraction methods.

Large-scale mill dosifier. Project Healthy Children 2011

Taking wheat flour as an example, using 2008 prices, it costs $268 to produce one metric ton (MT) of wheat flour and $312 to buy one MT of wheat flour. The cost of premix to fortify this wheat flour falls between $1.50 and $3.00 per MT when fortifying with iron, folic acid, and other B vitamins [51], which is an infinitesimal portion of the production costs. This rises to $8 per MT when vitamin A is added [63]. Fortificant cost can, however, range up to $15–20 per MT, depending on the vehicle being fortified, production capacity of the facility, and other addition factors. To put metric tons into perspective, a large-scale flour production facility may produce in the range of 48 MT per day or greater. In most cases, however, production within these large facilities is more on the magnitude of 250 MT per day.

Premix should be sourced from companies that have already received quality approvals from global nutrition bodies. For example, the Global Alliance for Improved Nutrition (GAIN)’s Global Premix Facility has already approved a number of companies around the world as quality premix supplies and is available to provide procurement assistance to facilities as needed.

The timing of premix addition into the production line is important to consider (due to premix’s sensitivity to heat) and needs to be thoroughly mixed in with the final product. Premix should be added before any processing steps that require high temperatures to avoid nutrient degradation but before the final product is mixed (to ensure homogeneity).

Large-scale flour fortification production. Project Healthy Children 2011

Step 2: Establish internal quality assurance and quality control measures. Fortification quality assurance and quality control measures are needed to ensure the product meets the established national standard for safety and efficacy. These measures should be incorporated into the production facility’s already established protocols for hygiene and safety. The East, Central, and Southern African (ECSA) Community has established quality assurance and quality control guidelines, which outline the specific type and number of qualitative and quantitative tests that should occur.

Quality assurance procedures and qualitative testing equipment for the facility can range from $3,000 to $8,000 [64]. Qualitative tests can range from $2 to $5 per test (conducted daily), while periodic outside quantitative testing (usually conducted every month or every few months) can range from $10 to $100 per test [63]. There is a significant range in up-front costs, generally speaking, from $6,000 to $40,000, in addition to the cost of premix and quality testing (considered recurring costs). However, these estimates are highly dependent on production parameters, the type of fortification vehicle, and nutrients chosen. As a result, these numbers should be seen as gross generalizations that pertain mostly to the production of fortified flour. Each specific situation will differ.

Finally, new packaging that designates the product as fortified is required. In many cases, this simply includes the addition of the country or region’s designated fortification logo.

Financial assistance to industry is sometimes provided by outside donors or government for the first year or two. However, up-front costs, in most cases, can be recouped by industry through the market advantage fortification gives producers (via consumer demand and regional fortification regulations). Additional costs may be folded into the price of the final product and either absorbed by the company or passed on to the consumer. Even when all programs costs are passed on to the consumer, the price increase tends to be only 1–2 % on top of the usual price—an amount that is less than normal market price variation [5].