Rice, however, has been largely conspicuous in its absence from the list of fortification vehicles, even though the areas of the world where it is a staple food correspond closely with the regions where there is a huge problem with ‘hidden hunger’ – where the food might be there but the micronutrients aren’t.
One of the reasons rice hasn’t been part of food fortification efforts to date is because of the technical and practical fortification challenges.
“Fortifying rice is not as simple as fortifying maize,” explained Anthony Hehir, director of the Nutrition Improvement Program at the world’s biggest nutrient supplier, DSM, which has supported global efforts for many years through its micronutrient expertise and programmes like Sight and Life.
“Micronutrients are usually in powder form and can be easily mixed with flour and even distribution achieved throughout the product. This isn’t the case with rice, because the rice and the micronutrient powder will separate."
Looks like rice, cooks like rice, tastes like rice…
Some years ago DSM developed a technology for producing a reconstituted rice kernel that combines rice flour with micronutrients.
“We grind broken rice kernels into a rice flour product, blend this with a premix, heat with steam and water to create a dough, and extrude the dough into a shape that resembles rice kernels. The kernels look like rice, cook like rice and taste like rice. They can be added at about 1% to conventional rice,” said Hehir.
Realising the potential
Although the technology has been available for some years, Hehir said it is only now that governments and international food aid organisations are starting to see rice as a big potential target for fortification.
“10 years ago the knowledge was there but the intervention at public health level wasn’t.
"There is a lot of talk about rice fortification in Asia, Latin America and also the US – which is working towards fortification of all rice that is donated as foreign aid.”
Two countries already have rice fortification programmes in place: Costa Rica, whose consolidated milling industry makes implementation relatively straightforward, and Papua New Guinea, where it has been mandatory for a number of years.
With trials underway in Bangladesh, Indonesia and some states of India, rice fortification is finally becoming a reality in other countries too.
DSM is also working with the Base of Pyramid (BoP) hub — a non-profit group which aims to combat poverty through commercial solutions — to provide the 350,000 migrant workers in Singapore at risk of hidden hunger with fortified rice. Bags of enriched rice are soon to be sold to caterers in Singapore under a social enterprise named ‘45rice ’.
Salt iodisation is another focus area for food fortification efforts, as it protects people against iodine deficiency, which affects cognitive development and IQ.
A seven-year salt iodisation project led by GAIN (Global Alliance for Improved Nutrition) and UNICEF and supported by the Bill and Melinda Gates Foundation has just run its course. In the process it has helped to protect 466 million people – Including 113m children – against iodine deficiency, according to GAIN.
The project ran from 2008 to 2015 in 13 countries: Bangladesh, China, Egypt, Ethiopia, Ghana, India, Indonesia, Niger, Pakistan, Philippines, Russia, Senegal, Nigeria and Ukraine. A recent report showed that over this period the availability of adequately iodised salt increased from 2.27 billion to 2.74bn people.
Salt iodisation has helped decrease the number of countries classified as ‘iodine deficient’ from 54 in 2003 to 25 in 2015, according to GAIN. Universal salt suffering from stunting and sight problems, is considered to be achieved if adequately iodised salt is present in over 90% of households within a country.
In other Asian and African countries, meanwhile, GAIN is working to achieve fortification of staples such as oil and flour with vitamin A, folic acid, iron and zinc. Zimbabwe, Zambia and Sudan are some of the newer target countries within this long term programme.
Reaching the unreachables
Greg S Garrett, director of food fortification at GAIN, said the good news was that national surveys in South Africa, Tanzania, Uganda, Nigeria and one Indian state had confirmed that large scale food fortification is reaching more vulnerable populations even in rural areas.
“In the past there has been a perception that these programmes might not be reaching the more vulnerable people,” he said.
However, the surveys also highlighted that there was “room for improvement” in food quality, with inadequate fortification a problem.
And this isn’t the only barrier to the success of large scale fortification initiatives, as Garrett explained.
“A major barrier is that fortification is not as prioritised as it could be. We work in Afghanistan where we are trying to fortify wheat flour, oil and salt, but other things are often seen as a higher priority,” he said.
Going forwards he said that GAIN would hope to support fortification activities in Zimbabwe, Zambia and Sudan as well as Angola, Chad and the Democratic Republic of the Congo, where there are opportunities. However, he emphasised that large scale fortification was not a quick fix and that there was still work to be done in countries with established programmes, such as India, Nigeria and Ethiopia.
Beyond staple food fortification
Of course food fortification is just one approach to tackling malnutrition and deficiencies.
GAIN, for example, manages the Marketplace for Nutritious Foods, which incubates companies that are bringing to market affordable nutritious foods. So far 37 businesses in Kenya, Mozambique, Rwanda and Tanzania have been awarded grants of between €45,000 and €50,000 under the scheme.
Beneficiaries have included a company in Nairobi which transforms offal into high protein chicken stock, and companies in Ghana and Cote D’Ivoire who are producing healthy complementary foods for children.
Then there is supplementation at a population level, a challenge that has been accepted by Vitamin Angels, an NGO whose remit is providing high dose vitamin A and deworming tablets to under-5s, and prenatal vitamins to pregnant and breastfeeding women.
“We are incredibly proud of the growing impact we are having in the fight against undernutrition. In 2015, Vitamin Angels had our biggest year yet, reaching over 48m beneficiaries globally - a 33% increase in beneficiaries reached over 2014. Our goal is to continue to reach more populations in need, and improve the quality of services provided,” said Jamie Frederick, monitoring and evaluation specialist at Vitamin Angels.
The World Health Organisation (WHO) identifies countries experiencing moderate to severe vitamin A deficiency – these are the countries where Vitamin Angels prioritises its efforts, and include 25 African nations, 15 Asian countries, and 15 countries in South, Central and North America.
India: a cause for concern
Frederick noted that one of the countries experiencing an exceptionally high rate of vitamin A deficiency in children under five is India.
“37% of all children with vitamin A deficiency live in India. Over the past several years we’ve focused on expanding our work in India – reaching over 10m children in India alone last year and targeting 12m this year.”
In common with GAIN, Vitamin Angels, which works with a large number of ingredient suppliers, said that reaching at-risk individuals was one of the main barriers to combating malnutrition.
Frederick said Vitamin Angels attempted to overcome this by partnering with field partner organisations to add its vitamins and educational health programming to their existing health and nutrition services.
“Our field partner organisations make it possible to reach these at-risk populations with vitamins – especially those who do not have access to government health programmes,” she said.
We've seen our vits in action in the Peruvian Andes- now our team's seeing their effects in the Amazon! pic.twitter.com/EaGe05QK8p— vitamin angels (@vitaminangels) July 10, 2016
Move towards multi-micronutrient supplements
The WHO’s guidance for supplementation during pregnancy currently focuses on iron and folic acid. However, in recent years, research has shown that outcomes are improved when women take a range of vitamins and minerals.
“Organisations are calling for the WHO to revise guidelines to reflect evidence that multiple micronutrient supplements are more effective than folic acid and iron alone,” said Hehir.
He reported that in this context, multi-micronutrient formulations such as DSM’s ’15’ had “gained a lot of traction in the past year”. Some governments, for example, are running programmes with this supplement.
Whilst there are numerous projects underway to tackle malnutrition, the challenge is vast, and food-based strategies are just one part of the picture. Malnutrition is a multi-faceted issue requiring a holistic solution, and water, sanitation, agriculture and dietary practices all need to be addressed.