Global Data Visualizations

Number of countries with data comparing population health outcomes before and after mandatory fortification.

The purpose of mandatory food fortification is to improve health outcomes in a population. Health improvements can be measured in changes in blood biomarkers (e.g., levels of iron in blood, as serum ferritin) and/or changes in functional outcomes that are caused by a deficiency in a nutrient (e.g., number of neural tube defects after fortification with folic acid).

To assess whether a mandatory food fortification program has led to health improvements, an outcome is measured both before and after fortification and evaluated for any change (e.g. increase in serum ferritin after the inclusion of iron in a fortification program). Evaluations should also assess programmatic reasons (e.g., proportion of food fortified, coverage of the fortified food in the population) why a program may have been successful or not successful. However, sometimes programmatic data are not available – in these cases, usually just before fortification and after fortification health outcomes are measured and compared.

GFDx has collated mandatory food fortification program evaluations or surveys of various health status changes before and after mandatory fortification. GFDx noted whether the health status change was one of the following:

• A positive health change: an increase in continuous values or decrease in deficiency values; statistically tested by study authors.
• A negative health change: a decrease in continuous values or an increase in deficiency values; statistically tested by study authors.
• No change: no statistically significant difference in health status, before and after fortification.
• Cannot determine: no statistical test conducted.

However, GFDx has not reviewed the evaluations or surveys for programmatic data to assess whether any health status changes can be attributed to fortification. The purpose in collecting this information is to ensure that evaluations and before and after surveys are known and available to all stakeholders. Using this information can improve transparency to all stakeholders regarding the information that is available in their country, but stakeholders must use their own programmatic data to determine why any health status changes may have occurred.

Questions to consider when interpreting data on health status changes before and after fortification, and their implications:

• What population consumes industrially produced versions of this food?
  • Implication: Differing food consumption patterns among subpopulations may affect whether there is a health status change before and after fortification. For example:
    • Fortification is most feasible when the food is industrially produced. Some populations may be more likely to consume non-industrially produced versions of that food. Rural populations may be more likely to consume self-grown and milled rice or village-milled flour, which are not industrially produced. If there is a population that is not consuming an industrially produced food, then there will likely be no health status change after fortification.
    • The food may not be a staple food (widely and regularly consumed) for a subpopulation. Take for example, Nigeria, where there is no dominant staple cereal grain – maize flour, rice, and wheat flour are all available for consumption in similar amounts. Although there is mandatory fortification of both maize flour and wheat flour in Nigeria, there will be little health status improvement from flour fortification in the population that predominantly consumes rice.
• What proportion of the food in the country is fortified (compliance or quality data)?
  • Implication: Fortification standards are generally designed to provide an average target nutrient intake from fortification. Poor fortification compliance means that this intended level of micronutrients is not being consistently added to foods, and likewise are not reaching the population. As a result, there may be no health improvements from fortification.
• What is the population coverage of the fortified food?
  • Implication: Low population coverage of the fortified food means that there are people who are not consuming the fortified food – which would reduce expected health improvements from fortification across the larger population.

Ideally, before expending resources on a post-fortification evaluation, countries should assess the implementation of their fortification program to see that it is operating well, particularly to ensure there is high compliance and adequate population coverage of the industrially produced food over a time period long enough to reasonably expect that a health improvement has taken place.

Follow these steps to download data from the visualization as an Excel or CSV file:

• Click on the “Data” tab at the bottom of the visualization window.
• Hover over the header row of the table until an ellipses (three dots […]) appears.
• Click on “more options” and a drop-down menu will appear. Select “Export data.”
• In the new window, select the export format that best supports your needs and click the “Export” button.

• GFDx has only included biomarkers or functional outcomes that can be definitively linked to a specific nutrient. GFDx recognizes that fortification may affect many additional outcomes that could not be included in this collation of data.
  • Excluded outcomes include:
    • Birth defects other than neural tube defects
    • Adverse outcomes that are not biomarkers of nutrition status (e.g. cancer, malaria)
    • Multi-factorial health and health-sensitive outcomes, which cannot be attributed to a specific nutrient, e.g.:
      • economic activity, productivity, school performance
      • anemia and hemoglobin concentrations
      • cognition outcomes

If you would like further methodological details, please contact GFDx at info@fortificationdata.org or consult the GFDx Data Dictionary.

Country classifications of income status and geographic region are from the World Bank and United Nations, respectively.

Global Fortification Data Exchange. Map: Availability of data on health status before and after mandatory fortification. Accessed dd/month/yyyy. [http://www.fortificationdata.org].