For 20 years, PATH has supported large-scale food fortification (LSFF). Most notably, we shepherded “UltraRice” towards large-scale adoption, advancing the technology itself (fortified “rice” kernels as fortificant with regular rice as the vehicle); building evidence; and enabling governments, multilaterals, NGOs, and other partners to bring it to consumers in Brazil, Burundi, Cambodia, India, and Myanmar.

This included promoting the use of ingredients that meet international regulatory standards and developing technical guidelines to ensure the integrity of the product throughout transport, storage, washing, rinsing, and cooking. We’ve supported dozens of clinical trials, acceptability studies, and market introductions in communities with varied cultural practices and nutritional needs.

This experience has given us invaluable, transferrable skills to build evidence of safety and effectiveness; support the establishment of policies and regulatory environments; develop technical guidelines; support processors with technology and quality; build supply chains; evaluate feasibility of roll-out and scale-up; and develop commercial models.

Our expertise in clinical trials, product testing, human-centered design, and policy advocacy, along with our regular collaborations with industry as well as our participation in high-level global and national technical working groups can further the range of actions needed within LSFF.

PATH offers comprehensive, LSFF technical support to partners in the public and private sectors, and at local and global levels. Our team brings an expert, unbiased perspective to assessing nutrition needs, identifying challenges, and introducing solutions for industrial fortification.

Public sector

PATH walks alongside governments as they develop strategy, policy, regulation, and standards for LSFF. We build the necessary clinical evidence to guide policy decisions and then help integrate LSFF into public programs. For example:

• In Myanmar, we engaged in feasibility analysis; established a standards-setting technical working group; prepared composition proposals and production guidelines; and developed branding, a quality seal, and a unified logo to create a unique identity and means of confirming compliance. With PATH support, the country developed safety standards, launched technical guidance, established policy, and began replacing regular rice with fortified rice national school feeding programs.
• With PATH’s support, the Food Safety and Standards Authority of India (FSSAI)—the country’s highest food regulator—formulated staple food fortification regulations. We now serve on multiple advisory committees and as a technical partner to the FSSAI, the Department of Food and Public Distribution, Bureau of Indian Standards, the government think-tank NITI Aayog, and the Food Fortification Resource Centre, as India aims to replace regular rice with fortified rice in all social safety net programs by 2024.

Private sector

PATH helps private sector to align supply and demand, to sustainably scale LSFF. We encourage manufacturers to develop marketable, compliant, fortified products, build resilient supply chains, and establish simple quality assurance/quality control (QA/QC) systems. For example:

• In Burundi, we supported operational efficiencies and QA/QC for blending fortified kernels with the vehicle. There, and in Cambodia, we studied shelf-life, micronutrient stability, and bacterial growth, to identify how to extend shelf-life in various climates for cost savings.
• In India, we helped 15 millers develop technical guidelines; conducted technology transfer; supported QA/QC; built supply chains; and evaluated roll-out and scale-up feasibility. Currently, we are landscaping rice and premix manufacturers to understand market dynamics and strengthen engagement for commercial introduction.

We also apply our expansive capabilities to strengthen free market production, procurement, and distribution. For example:

• In Brazil, PATH worked on a pilot to scale up fortified rice kernels through commercial channels. We considered fortificant production capacity, supply chain development, distribution channel and market development, demand generation, and knowledge dissemination.

Civil society

PATH identifies barriers and enablers to bring policy and private sector work to implementation and scale. We partner with civil society organizations (CSOs), academic institutions, market actors, and public sector to design programs, generate evidence, bridge data gaps, and ensure compliance. For example:

• PATH co-developed the Q-Plex Micronutrient Array, an affordable, easy-to-use tool which improves surveillance of vitamin and mineral deficiencies versus infections and inflammation. Having successfully implemented this in Niger and Tanzania, we plan to it use to help governments build capacity for population surveillance. This will support evidence-based decision-making regarding fortification versus or in combination with other means of addressing micronutrient deficiency.
• To build CSOs’ capacity to carry out evaluations, for 18 evaluations in 12 countries, PATH selected grantees and managed funding; paired CSOs with researchers; provided technical support on data collection, interpretation, and analysis; strengthened knowledge dissemination, and published this best practice model.
• In Uganda, PATH developed a Community Mobilization and Action Planning Curriculum to help CSOs and community members in Uganda identify local problems and advocate with leaders to strengthen policies, budgets, and programs.

Global commitment

PATH works to improve coordination, collaborations, complementarity, and synergies among donors and other key stakeholders. We support Scaling Up Nutrition (SUN)-- including the SUN Business Network, the World Food Programme (WFP), and others to support fortification within public health and food systems activities. For example:

• In Myanmar, we coordinated a technical working group of donors and other stakeholders to inform national guidelines and are working with SUN on food-based dietary guidelines.
• In Cambodia, PATH worked with the Ministries of Fisheries and Health and WFP on a clinical trial, providing evidence that fortified rice improved cognition, serum zinc and serum folate concentrations, vitamin A status, and hemoglobin and that hookworm infection negatively impacted cognitive performance and iron status.
• In Burundi, Cambodia, and Myanmar, we have collaborated with food assistance investments of USDA McGovern-Dole, USAID Bureau for Humanitarian Assistance (formerly under Food for Peace), WFP, and others to promote the use of fortified staples. Through our work, fortified rice is now on the USDA commodity list, for use by USG-supported programs.

PATH pairs its unique strengths with collaborators’ expertise to develop, deploy, and scale appropriate health solutions at local, national, regional, and global levels. Together we engage in research not only to contribute to the evidence base, but also to help governments take informed action and companies sustainably bring context-appropriate products to market.

Piloting a commercial model for fortified rice: Lessons learned from Brazil.
Milani P, Spohrer R, Garrett G, Kreis K. (2016). Food and Nutrition Bulletin Vol. 37(3) 290-302.

Social marketing of a fortified staple food at scale: Generating demand for fortified rice in brazil.
Milani P, Carnahan E, Kapoor S, et al. (2017). Journal of Food Products Marketing 23(8):1-24

Multi-micronutrient fortified rice improved serum zinc and folate concentrations of Cambodian school children. A double-blinded cluster-randomized controlled trial.
Kuong K, Tor P, Perignon M, Fiorentino M, Chamnan C, Berger J, Burja K, Dijkhuizen M, Parker M, Roos N, Wieringa W. (2019). Nutrients 11(12). pii: E2843.

Effect of multi-micronutrient-fortified rice on cognitive performance depends on premix composition and cognitive function tested: Results of an effectiveness study in Cambodian schoolchildren.
Fiorentino M, Perignon M, Kuong K, de Groot R, Parker M, Burja K, Dijkhuizen MA, Sokhom S, Chamnan C, Berger J, Wieringa FT. (2017). Public Health Nutrition 21(4):816-827.

Cognitive performance and iron status are negatively associated with hookworm infection in Cambodian schoolchildren.
Kuong K, Fiorentino M, Perignon M, Chamnan C, Berger J, Sinuon M, Molyden V, Burja K, Parker M, Ly SC, Friis H, Roos N, Wieringa FT. (2016). American Journal of Tropical Medicine and Hygiene 95(4):856-863.

Impact of multi-micronutrient fortified rice on hemoglobin, iron, and vitamin A status of Cambodian school children: A double-blind cluster-randomized controlled trial.
Perignon M, Fiorentino M, Kuong K, Dijkhuizen M, Burja K, Parker M, Chamnan C, Berger J, Wieringa F. (2016). Nutrients 8(1):29.

Micronutrient-fortified rice can increase hookworm infection risk: A cluster randomized trial.
de Gier B, Ponce MC, Perignon M, Fiorentino M, Kuong K, Chamnan C, Parker M, Burja K, Dijkhuizen MA, Berger J, Polman K, Wieringa FT. (2016). PLoS One 11(1):e0145351.

Evaluation of the effect of Ultra Rice® EDTA supplementation on the soluble iron, visual acceptance, and vitamin A stability of commercial milled rice blends.
Johns, P., Gaurav Patel, Megan E. Parker, J. Lasekan, Peiman Milani, M. K. Nixon, M. Tigner and Daniel J. Schmitz. (2015). International Journal of Food Science and Technology 50: 1615-1624.

In vitro assay of iron in fortified rice analogues.
Johns PW, Parker ME, Patel GC, Lasekan JB, Frey M, Matthias D, Chanin ZB, Forsman CF, Schmitz DJ. (2014). Food Analytical Methods 7(4):902–911.

A blinded, cluster-randomized, placebo-controlled school feeding trial in Burundi using rice fortified with iron, zinc, thiamine, and folic acid.
Parker ME, Mosites E, Reider K, Ndayishimiye N, Waring M, Nyandimbane G, Masumbuko D, Ndikuriyo L, Matthias D. (2015). Food and Nutrition Bulletin 36(4):481-92.

Micronutrient-fortified rice improves haemoglobin, anaemia prevalence, and cognitive performance among schoolchildren in Gujarat, India: A case-control study.
Mahapatra S, Parker ME, Dave N, Zobrist SC, Shajie D, King A, Betigeri A, Sachdeva R. (2021). Int J Food Sci Nutr 1-14. doi:10.1080/09637486.2020.1855126

Photo: PATH/Minzayar