Can Large Scale Food Fortification Plug Nutrition Deficiency?

Micronutrient deficiencies account for 7.3 per cent of the global burden of disease and their impacts on individuals, families and countries are devastating. The World Health Organisation (WHO) estimates that 42 per cent of children less than 5 years of age and 40 per cent of pregnant women globally are anaemic. 

Deficiencies in children’s diet

Over a million children die every year due to iron and vitamin A deficiencies. This situation necessitates urgent interventions to improve the global nutrition status. One of the most effective, scalable and sustainable ways to tackle this situation is the fortification of staple foods such as rice, wheat, salt, oil and milk. 

Though staples are primarily fortified through mass fortification to address public health concerns, food manufacturers can voluntarily fortify foods available in the market. This is known as market-driven fortification or industrial fortification or large-scale food fortification (LSFF). While mass fortification is nearly always mandatory, LSFF is always voluntary, but governed by regulatory limits. It is important to note that LSFF does not include biofortification or household/community fortification.

LSFF is ranked one of the highest-return interventions in global development. Food industries can save millions of lives if food is fortified adequately. In addition to preventing micronutrient malnutrition, LSFF targets to improve health and wellness of individuals.  By increasing the levels of specific nutrients, food manufacturers create avenues to add value to their product categories. 

The concept of food fortification is more than a century old. The major milestones in the food fortification journey globally are depicted in Figure 1. 

Need for LSFF in India 

India is ranked #101 out of 116 countries in the Global Hunger Index 2021, with a hunger level considered as serious. It has also reached a peak in the nutrition crisis with alarming levels of micronutrient deficiencies. A meta-analysis of 270 articles (J. Nutr. Sci., 2021, vol. 10) reveals the pooled age-wise prevalence of six preventable micronutrient deficiencies (vitamin A, folic acid, vitamin B12, vitamin D, iodine and iron) in India (Figure 2). Over 60 per cent of the Indian population suffers from vitamin D deficiency, 54 per cent are iron deficient and 53 per cent of the population have vitamin B12 deficiency. The Comprehensive National Nutrition Survey of India (2016-2018) further reveals one-third of the adolescent population (10-19 years) and one-fifth of the pre-school population (1-4 years) are zinc deficient. This situation calls for serious actions to improve the micronutrient status in the country.  

Figure 2: Prevalence of micronutrient deficiencies in India

The Government of India recognises food fortification as a key intervention to address multiple micronutrient deficiencies. Focus on food fortification in India began in the 1950s. Its major chronological development is depicted in Figure 3.

Figure 3: Key food fortification milestones in India

LSFF as an emerging business opportunity

1. New era of health foods – The rise of health enthusiasts clearly indicates that consumers are moving towards healthy foods and ingredients, rather than just the taste. This trend offers opportunity for industry and entrepreneurs to position themselves as industry leaders in this budding business area and sell high quality healthy products. 
2. Requires limited changes in consumer behaviour – Since LSFF does not change the characteristics of the food in terms of taste, aroma, texture and appearance, consumers can quickly adapt to and accept this new segment of foods with minimal changes in behaviour. 
3. Adds products & brand value – Due to additional nutrients, fortified products are seen as having higher value than other similar products on the shelves. Customers tend to choose the healthier option, adding pressure on competitors to follow suit. This gives a competitive advantage to the product brand, helping it to stand out.
4. Cost-effective intervention – WHO states that fortification is not only cost effective (i.e., is a cheaper way to increase micronutrient intake compared with other interventions that have the same aim), but also has a high cost–benefit ratio (i.e., is a good investment). Depending on the food and the vitamins and/ or minerals added, fortification costs only $0.05 to $0.25 per person per year. The gains in productivity and savings to a nation’s healthcare system are many times this cost. In addition, LSFF can be implemented taking advantage of existing technology, infrastructure and local distribution networks, thus saving initial capital costs. As per several studies, end-consumers have reported that the price of fortified foods is not a significant barrier to purchase. 
5. Growing market – The fortified foods industry has seen enormous growth in recent years. In 2021, the market size value was estimated at $172.4 million. Between 2021 and 2031, it is expected to increase at a CAGR of 6.3. The key drivers of the fortified foods market over the forecast period were identified as rising health concerns and an increase in disease rates.

Key players along the LSFF value chain 

The LSFF value chain (Figure 4) includes several players at different levels. 

Figure 4: Food fortification value chain 

At the industrial processing level, equipment manufacturers (e.g. extruders, blenders, spray dryers) and technology providers (e.g. dosing technology; drying technology) are involved. Food technologists play a crucial role in determining which processes and distribution systems to adopt for nutrient retention and the strategies to minimise loss caused by nutrient stability. The fortification process involves manufacturers and suppliers of the premixes, antioxidants and stabilisers. It also requires a specialist in the nutrient delivery systems (e.g. encapsulation technology). The QA & QC involves food laboratories equipped to test vitamin and mineral levels in the fortified foods. To ensure stability of the nutrients during storage, appropriate packaging is crucial. The marketing of fortified foods involves the retail organisations. The regulations/market specialist gathers information on the nutrient stability to make statements/ claims on labels and advertising.

Emerging segments & innovations in LSFF

Fortified dairy products dominated the fortified food market in 2020 and is expected to grow with the highest CAGR of 6.8 during 2021 to 2026. The dairy sector has the advantage of being naturally a rich source of calcium. Keeping in view the vitamin D and calcium synergistic effects, and that vitamin D deficiency is a current public health concern in India, the dairy sector forms the ideal vehicle for its fortification. Dairy products such as lassi, buttermilk, yogurt etc., are being fortified in a big way.  Vitamin D fortified non-dairy beverages such as soy/ almond milk are also gaining momentum, along with vitaminised water, and fortified fruit juices. Another popular segment with an increasingly health-conscious market is the micronutrient fortified energy dense (MFED) foods. These are energy rich foods with added essential micronutrients which can support growth & development and can also serve as a meal replacement. E.g. fortified breakfast cereals (cornflakes, wheat flakes etc.), fortified pasta & noodles, fortified bread etc.

Regulatory aspects

The Food Fortification Resource Centre (FFRC) was established by FSSAI in 2016 as the nodal agency to support and promote LSFF in India. FRRC facilitates stakeholders embarking on LSFF and provides guidance in terms of fortification standards, food safety, technology, premix, equipment, and quality assurance & control.

In 2018, fortification standards for five staple foods (wheat flour, rice, milk, oil, and salt) and the fortification logo were released in the Food Safety and Standards (Fortification of Foods) Regulations and enforced from January 1, 2019. More recently, FSSAI has released standards for processed foods such as breakfast cereals, buns, rusk, pasta, noodles, fruit juices, etc. These norms are part of the Food Safety and Standards (Fortification of Foods) First Amendment Regulations, 2020, which came into effect from July 1, 2021. 

Manufacturers of fortified foods need to comply with the pre-set level of micronutrients as specified in the regulations. Recently, FSSAI specified “the fortified processed food shall provide 15-30 per cent of the Indian adult RDA (Recommended Dietary Allowance) of micronutrient, based on an average calorie intake of 600 kcal from processed foods (approximately a third of daily energy requirement for an adult). This excludes foods high in fat, salt and sugar (HFSS). In addition, manufacturers of fortified foods need to submit an undertaking of quality assurance to the Food Authority twice a year. All fortified foods need to be packaged in a way that takes into consideration the nature of the added fortificant and its effect on the shelf life of the food. Package should bear the label “fortified with … (name of the fortificant)” and the fortification logo, “+F”, developed by FSSAI. It may also include the tag line “Sampoorna Poshan Swasth Jeevan” under the logo.  These initiatives provide an impetus for industry to embark on LSFF. 

Challenges involved

Although LSFF is a promising venture, it is often accompanied by several challenges. 

Technical challenges:

• In case of double, triple or multiple fortification, the added micronutrients shouldn’t create an imbalance of essential nutrients in the food;
• The fortificant should be stable under normal conditions of storage and use. It should also be stable during the formulation process, preparation and processing;
• Scaling up LSFF – Batch processing is labour intensive and has limited capacity. E.g. Continuous blending of fortified kernels into rice is desirable instead of batch blending;
• High capital cost during initial investment to scale up and lack of access to affordable finance

Regulatory challenges:

• Financial barriers e.g. excessive registration, taxes on fortification inputs, etc. 

End user challenges:

• Lack of awareness on the benefits of fortified foods and lack of awareness on own micronutrient deficiencies

Dr Manjula D Ghoora, Consultant, Food Processing & Retail Practice, Sathguru Management Consultants