The World Health Organisation (WHO) estimates that more than two billion people are deficient in key vitamins and minerals, particularly vitamin A, iodine, iron and zinc. Most of these people live in low income countries and are typically deficient in multiple micronutrients. The groups most vulnerable to micronutrient deficiencies are pregnant women, lactating women and young children. Despite recent economic growth and advances in health and development in Asia, micronutrient deficiency remains high.
More than one in three children under age five in Indonesia are estimated to be stunted, which means they will never achieve their growth potential due to chronic undernourishment during critical growth years. Overall, the prevalence of stunting in the Southeast Asian region hovers around 27 percent. These children will become less productive, lower earning adults, with a higher vulnerability to disease, making it more difficult to escape the cycle of poverty.
In addition to contributing to stunting, micronutrient deficiencies cause a range of health consequences, increased public health costs and reduced economic growth.
For example, severe iodine deficiency during pregnancy can lead to permanent cognitive impairment of the child. Zinc deficiency increases the risk of diarrhoea in young children by a third; vitamin A deficiency is the most preventable cause of blindness; and iron deficiency anaemia can lead to maternal death.
Often, significant proportions of the population are mildly to moderately deficient, but due to a lack of visible symptoms, this goes largely unnoticed. This fragile status-quo creates heightened vulnerability to shocks, such as drought or conflict, or increased micronutrient needs during pregnancy. It is also why micronutrient deficiency is referred to as “hidden hunger.”
Wealthier, But Not In Health
Economic development and urbanisation in Asia are two double-edged swords for nutrition. Increased incomes have led to more diversified diets from mainly rice to more nutrient-rich fruit, vegetables, meat, fish, eggs, and milk. However, at the same time, advances in the food industry, modernising food retail and supply chains, and changing urban lifestyles have driven up the consumption of processed, packaged and ready-to-eat products.
These foods are an affordable, accessible, and convenient source of calories, but are often energy dense— high in calories, fat, sugar, and sodium. Overweight and obesity are emerging health problems in many countries around the world.
According to the 2015 Global Nutrition Report published by the International Food Policy Research Institute, in all countries but one where WHO data is available, the prevalence of adult overweight and obesity are increasing. We now face a double-burden of malnutrition, including both undernutrition and overweight in the same countries.
Micronutrient deficiency is a complicated problem linked to several root causes including poverty, lack of access to proper nutrition, and poor sanitation—these result in poor diets lacking in sufficient micronutrients for proper physical growth and cognitive development. One way to alleviate this problem is through food fortification, the addition of micronutrients to staple foods and condiments. This is a proven, cost-effective solution to deliver micronutrients through existing food systems to large segments of the population where nutritional gaps in the diet exist.
Fortification And The Food Industry
The food industry has a key role to play in fortification. At the processing stage, a micronutrient mixture or ‘premix’ is blended into the product being fortified. Iron, folic acid and other B vitamins, and zinc are typically added to wheat flour or rice, while fat-soluble vitamins A and D can easily be mixed in with edible oils.
Micronutrients can also be added to popular condiments such as fish and soy sauces and seasoning powders. As popular Asian convenience foods such as instant noodles and snacks are composed mainly of wheat flour, salt, seasoning, vegetable oil, and sugar, these provide consumers with easy access to fortifiable commodities. The gravitation from traditional diets toward modern, industrial supply chains in Southeast Asia therefore facilitates food fortification.
The Global Alliance for Improved Nutrition (GAIN) recently released a Fortification Snapshot Report, which documents the progress made globally over the last century in food fortification and outlook for the future. Starting with the iodisation of salt, countries in North America and Europe have been adding micronutrients to foods since the 1920s. This has contributed to the virtual eradication of diseases such as goiter, rickets, beriberi, and pellagra in these regions.
However, fortification alone cannot resolve all micronutrient malnutrition; no single strategy can. Optimal breastfeeding and complimentary feeding practices, sound maternal health, clean water and sanitation, and a diverse, nutritious diet are all critical.
That said, food fortification is still beneficial as a feasible, low-cost intervention that can reach large segments of populations, without requiring any behavioural or dietary change or noticeably increasing individual food costs. It should not be seen as a replacement for, but as a complementary part of a comprehensive nutrition strategy.
Food Fortification Today
Today, we are seeing food fortification efforts everywhere around the world. Over 140 countries are implementing salt iodisation programs, 83 countries have mandated cereal grain fortification and dozens more are fortifying edible oils, sauces, and condiments. Many of these programs are in low- and middle-income countries.
However, with the exception of iodised salt, the majority of countries in Asia have not adopted mandatory fortification programs. Only three countries in Asia have mandatory wheat flour fortification with at least iron (Indonesia, Philippines and Nepal), and two have mandatory rice fortification (Papua New Guinea and Philippines). Oil fortification with vitamin A has been mandated in Bangladesh and Indonesia, but is not yet being implemented fully. While no countries currently mandate fortification of fish and soy sauce with iron, some companies in Cambodia and Vietnam are doing so voluntarily, and Thailand requires iodine to be added to its fish and soy sauce.
To date, the primary focus of mandatory food fortification programs has been primarily on staple foods or condiments— iodised table salt, fortified vegetable oil with vitamins A and D, and fortified wheat or maize flour with iron and folic acid.
Rice fortification has not been broadly adopted globally yet, mainly for technological and cultural reasons. However in recent years, the technology to fortify rice kernels has advanced so that micronutrients may be added without any noticeable change to the rice’s colour, taste, smell or cooking properties.
Adding iron to fish and soy sauce is also feasible from a technical and cost-perspective, and public-private partnerships in Cambodia, China and Vietnam have implemented condiment fortification with iron. Rice and condiments represent huge opportunities for Asia to improve the population’s micronutrient status through fortification.
Realising Benefits With Fortification
However, that said, fortification programs should not be limited to just raw staple foods available in the market. With urban lifestyles meaning less time to cook and an increasing abundance of convenience foods, it is more critical than ever that the processed and prepared foods (instant noodles, ready-meals, biscuits, bread, spreads, etc.), as well as ready-made meals produced by street vendors and restaurants, contain fortified ingredients including iodised salt, fortified wheat flour and/or rice, and fortified vegetable oil. The additional micronutrients do not affect the colour, taste or cooking properties of the food they are added to, but yet have huge health benefits for consumers.
A 2011 study found that in the US, food fortification largely contributed to total intakes of vitamins A, C, and D, thiamin, iron, and folate. Also, without fortification (and dietary supplements), many Americans would not achieve recommended nutrient intakes. This is a context where people are consuming large amounts of processed foods.
As Asia moves more towards this dietary context, the food industry has an opportunity to contribute in the fight against micronutrient deficiency. A 2013 paper calculated that a 75 g pack of instant noodles using fortified wheat flour would be able to provide around 50 percent of the recommended iron intake for children four to six years of age and over 10 percent for women of reproductive age. This does not include fortification of the accompanying seasoning packet.
Similarly, using iodised salt in instant noodles, soup stock, and soy sauce would contribute nearly 20 percent of the recommended daily allowance for iodine for adults.
There is probably no better example of how critical processed foods are to micronutrient intake than the case of iodised salt. It is estimated that 75 percent of salt intake in industrialised countries comes from processed foods including meat, cheese, ready-meals, fast food, snacks, and bread. If the salt used in these foods is not iodised, then the population would run a higher risk of becoming iodine deficient. This is why countries like Switzerland, Denmark, the Netherlands, Australia, and New Zealand all have some regulation in place regarding iodised salt in processed foods.
With similar consumption trends in Asia, it is important for the food industry to understand the nutritional context they are working in, and be part of the solution. Industries should be motivated to fortify and/or use fortified ingredients, where feasible. Governmental authorities also play a critical role to create an enabling regulatory environment to ensure clarity on standards for micronutrients to be added in safe and approved formulations and levels, as well as to monitor the health impact in the population.
For example, in one country in Southeast Asia, a survey found that despite mandatory salt iodisation legislation, some food companies interpreted the regulation to only apply to household salt, meaning that there is no requirement for food producers to use iodised salt.
Taking Fortification A Step Further
Despite lack of mandatory legislation, several companies in countries like India and Vietnam have started to take up voluntary fortification of edible oils, condiments, and seasonings. This is a commendable growing trend.
In order to really shift the needle, fortification should become the industry norm in countries where existing diets are insufficient to provide sufficient micronutrient intakes in the population. This is also where government plays a key role to provide guidance on the health status of the population, and to develop appropriate fortification standards.
If only selected brands contain added micronutrients, then fortification is not likely to achieve a public health benefit; rather it will benefit only select consumers. The additional costs to fortify foods vary, but are usually less than a fraction of one percent more than the non-fortified food. This cost is then diluted across the entire market, reducing costs per consumer even further.
One risk to voluntary fortification is that companies may claim that their products are more nutritious, which would drive increased consumption. Therefore, marketing messages should be considered with caution. Labels should be accurate, to avoid misleading consumers to increase their consumption of that particular product category.
The expansion of the Association of Southeast Asian Nations (ASEAN) Free Trade Zone will likely increase the flow of processed foods between countries, which means that governments should also review standards of fortified foods in order to ensure harmonisation and prevent barriers to trade.
The private sector is the lynchpin to successful fortification. Companies should ensure that consumers are not only satisfied with taste and quality of their products, but are also receiving a nutritional benefit. Fortification of staples and condiments is a proven nutrition intervention that has been used safely and effectively in developed countries for well over a century.
In a region where diets are rapidly changing, fortification should be a part of the food system in order to ensure a healthy, productive next generation. Of course, fortification alone cannot solve all micronutrient problems. Further, in the long run, we should all be working towards improving diets to comprise of whole foods including dairy, meat, fish, milk and eggs. But in the meantime, we can fight micronutrient malnutrition using the tools and technologies we have today.