Advancing large-scale food fortification to improve nutrition

Samples of fortified grains to be mixed with rice in Yangon, Myanmar. The micronutrients in the fortified grains can be customized to meet the needs of specific populations. Photo: PATH/Minzayar.

An estimated 2 billion people suffer from micronutrient deficiencies—a lack of essential vitamins and minerals that are key for optimal cognitive and physical development, disease prevention, and general well-being. Large-scale food fortification (LSFF), which adds essential micronutrients to staple food products or condiments such as maize or wheat flour, sugar, salt, bouillon cubes, soy sauce, cooking oil, milk, or rice, is a cost-effective, culturally sensitive strategy to improve global health.

Yet developing and introducing sustainable LSFF requires complex end-to-end technical assistance that is both informed by global manufacturing best practices and rooted in local communities and culture. It requires extensive collaboration between the public sector, the private sector, and civil society to coordinate strategies, policies, regulations, and standards that enable its success. Ultimately, the ability of LSFF to sustainably reduce micronutrient deficiencies and improve health outcomes is only as effective as the seamlessness with which it is integrated into the food system.

For the past 20 years, PATH has provided the public and private sector with trusted support to make LSFF part of the food system. This includes developing cost-effective technologies and quality control protocols for fortified foods, building evidence of their efficacy, integrating them into regulatory systems and markets, facilitating their large-scale adoption, and enabling their use in communities all over the world.

Notably, PATH pioneered the use of Ultra Rice® fortification technology—fortified “rice” kernels (the fortificant) packed with iron, zinc, vitamin A, thiamin, niacin, vitamin B6, folic acid, and vitamin B12 (in a premix) that are blended with regular rice (the vehicle)—and successfully introduced it to consumers in Brazil, Burundi, Cambodia, India, and Myanmar.

The nutritional benefits of Ultra Rice are abundant. As a result, PATH has worked with governments, multilaterals, nongovernmental organizations, and private-sector partners to develop and conduct clinical trials, product testing, and feasibility assessments; scale up resilient supply chains; and implement policy advocacy strategies to enable Ultra Rice’s widespread integration into communities. With PATH’s support, Cambodia and India established improved nutrition indicators among key populations (an impact evaluation for Myanmar is pending).

Our two decades-long experience providing end-to-end technical assistance for global LSFF programs like Ultra Rice has strengthened our ability to appropriately and effectively advance solutions to complex global health issues. Such solutions enable communities all over the world to live healthy, vibrant lives on their own terms.

The Cox family, a family of inventors in Washington State, originally developed fortified rice as a potential solution to vitamin A deficiency. In the 1990s, they gifted the technology to PATH, given PATH’s successful track record working with impacted populations to transition innovations from development through to implementation, evaluation, and scale and our ability to improve millions of lives through large-scale global health solutions. PATH brought decades of global health expertise to rice fortification, ultimately introducing the technology and scaling up its use alongside community partners around the world.

PATH provides expert support to the public sector, the private sector, and civil society across all stages of the rice fortification process: identifying the problem, conducting the necessary research, building evidence for decision-making, developing and refining technologies, bolstering policy and advocacy efforts, and implementing solutions. We work with all relevant key stakeholders to build a conducive environment for the development and integration of LSFF technology.

The technical assistance required at each stage looks different for every country; what works in one environment may not work in another due to differences in local governance, supply chains, cultural norms, and markets. We specialize in adopting our approach to fit local contexts, including diets and nutritional needs as highlighted below.

CAMBODIA

Hookworm infection in schoolchildren is associated with iron deficiency and lower cognitive performance. In Cambodia, PATH partnered with the Institut de Recherche pour le Développement, the Cambodia ministries of Agriculture, Forestry and Fisheries and Health, and the World Food Programme to conduct a large-scale clinical trial to build evidence that fortified rice enhances hemoglobin, vitamin A, and zinc levels to reduce morbidity and improve cognition.

Once this evidence was established, PATH supported private-sector and civil-society partners in developing high-quality fortified products that were shelf-stable and cost-effective in various environments. Our work in Cambodia provided the necessary evidence for the U.S. Department of Agriculture (USDA) to add fortified rice to the list of commodities that could be ordered for distribution through U.S. government food assistance programs. For the 2020 fiscal year, eight of the nine McGovern-Dole awards granted in sub-Saharan Africa and Southeast Asia obtained a total of 18.4 metric tons of fortified rice for their programs.

INDIA

As the second-largest producer of rice worldwide and the country with the highest micronutrient deficiency burden, India presented an important opportunity to develop LSFF programs. India also has the highest uptake of rice in its government safety net programs.

PATH supported the government of India’s Food Safety and Standards Authority and Department of Food and Public Distribution in determining feasibility, generating evidence on the impact of rice fortification, and developing regulations that would mandate the use of fortified rice in all safety net programs by 2024. In partnership with the Akshaya Patra Foundation, PATH launched a government-supported school feeding program in which children received midday meals with fortified rice and learned about nutrition and hygiene; its success prompted officials to scale up the program in additional locations.

Finally, to meet ongoing and future demand for fortified rice, PATH worked with the private sector to create a vibrant market of cost-effective production facilities that support local rice millers. Thanks to these efforts and partnerships, 1 million people in India have benefited from rice fortification programs to date. PATH is continuing to work in the country, with the goal of supporting 800 million people through fortified rice programs in the future.

MYANMAR

Myanmar has among the highest rates of malnutrition in Asia, especially for children and pregnant or breastfeeding women. Forty percent of pregnant women and more than 50 percent of children ages five through nine are anemic, and one-quarter of children suffer from chronic malnutrition (i.e., stunting). Working alongside the government of Myanmar and with support from the Livelihoods and Food Security Fund, PATH introduced fortified rice in Myanmar in March 2016 to reduce micronutrient deficiencies, improve mental and physical health and development, and stimulate economic opportunities.

Prior to the launch, PATH conducted a feasibility analysis, helped establish the Myanmar Rice Fortification Working Group to oversee the development of standards and production guidelines, proposed options for the composition of fortified rice, collaboratively established a brand identity, and worked to support fortified rice producers. PATH also helped draft national technical guidance and the first-ever National Rice Fortification Policy, both of which support the use of fortified rice in public assistance programs, such as school feeding programs. This support has been instrumental in establishing the evidence to set policy, scale up fortified rice throughout the country, and improve nutrition outcomes.

PATH’s work on LSFF, specifically our groundbreaking work on Ultra Rice, has had significant results:

• By enabling and promoting the use of fortified staple foods in Burundi, Cambodia, and Myanmar through the USDA McGovern-Dole International Food for Education and Child Nutrition Program, the US Agency for International Development’s Bureau for Humanitarian Assistance (formerly under the Office of Food for Peace), World Food Programme, and other investments, fortified rice is now on the official USDA commodity list—green-lighting its use in US government-supported food assistance programs. This recognition has immense implications for improving global nutrition, and it positions the US government as a leader in advancing sustainable global health solutions.
• We helped generate the world’s largest knowledge base for rice fortification and created a model for multistakeholder partnerships that is applicable for scaling up fortified staple foods in countries all over the world.

LSFF—and rice fortification more specifically—has proven to be a cost-effective and scalable solution for addressing micronutrient deficiencies in communities all over the world. Supported by our decades of experience in this area, PATH continues to provide comprehensive technical and advocacy assistance to governments and in-country partners to scale up the use of fortified rice.

In India, for example, PATH is currently extending support to 12 states (Andhra Pradesh, Assam, Bihar, Jammu and Kashmir, Jharkhand, Karnataka, Maharashtra, Manipur, Nagaland, Punjab, and Tamil Nadu) to increase awareness of, availability of, and access to fortified rice to reduce iron deficiencies in target populations. This PATH-led project will demonstrate how countries can affordably and effectively scale up the production and distribution of fortified rice to address areas of micronutrient malnutrition for years to come.

Adorella Alimentos Ltda. (Brazil)

Base of the Pyramid Innovation Center (Bopinc)

Bureau of Indian Standards (Ministry of Consumer Affairs, Food & Public Distribution) (India)

Business Kind (Myanmar)
Christy Foods Pvt Ltd (India)

Department of Food and Public Distribution (Ministry of Consumer Affairs, Food & Public Distribution) (India)

Federal University of Viçosa (Brazil)

Food Fortification Resource Centre (Ministry of Health & Family Welfare) (India)

Food Safety and Standards Authority of India (Ministry of Health & Family Welfare) (India)

Global Alliance for Improved Nutrition (Switzerland)

Gold Power (Myanmar)

Institut de Recherche pour le Développement / Research Institute for Development (France)

Institute of Statistics and Economic Studies of Burundi (Burundi)

Ministry of Agriculture, Forestry and Fisheries (Cambodia)

Ministry of Health (Cambodia)

National Institution for Transforming India (NITI Aayog), Government of India (India)

POSHTIK Network (India)

Terre Des Hommes (Switzerland)

Urbano Agroindustrial Ltda. (Brazil)

Usher Agro Ltd. (India)

World Food Programme (United Nations) (Italy)

World Vision International (United Kingdom)

Abbott Fund

Bill & Melinda Gates Foundation

James Percy Foundation

Livelihoods and Food Security Fund

Margaret A. Cargill Philanthropies

National Stock Exchange Foundation

US Department of Agriculture

UltraRice is a registered U.S. trademark of Bon Dente International, Inc.