Enablers and Barriers of Zinc Fortification; Experience from 10 Low- and Middle-Income Countries with Mandatory Large-Scale Food Fortification

Abstract

Adequate zinc nutrition is important for child growth, neurodevelopment, immune function, and normal pregnancy outcomes. Seventeen percent of the global population is estimated to be at risk for inadequate zinc intake. However, zinc is not included in the fortification standards of several low- and middle-income countries with mandatory fortification programs, despite data suggesting a zinc deficiency public health problem. To guide policy decisions, we investigated the factors enabling and impeding the inclusion of zinc as a fortificant by conducting in-depth interviews with 17 key informants from 10 countries. Findings revealed the decision to include zinc was influenced by guidance from international development partners and enabled by the assessment of zinc deficiency, mandatory regional food fortification standards which included zinc, the World Health Organization (WHO) guidelines for zinc fortification, and the low cost of zinc compound commonly used. Barriers included the absence of zinc from regional fortification standards, limited available data on the efficacy and effectiveness of zinc fortification, and the absence of national objectives related to the prevention of zinc deficiency. To promote zinc fortification there is a need to put the prevention of zinc deficiency higher on the international nutrition agenda and to promote large-scale food fortification as a key deficiency mitigation strategy.

Correlation between Zinc and Folic Acid Intake with Hemoglobin Levels in Pregnancy

“…Zinc in high levels and has easily absorbed properties is zinc derived from animal food ingredients. The zinc content of vegetable origin generally binds to oxalates, tannins, and phytates (Tarini et al, 2021) In this study, it was found that 57 people, or 89.1% of third-trimester pregnant women had low zinc intake. The reason for this is thought to be related to the type of food consumed.…”

Zinc nutrition and human health: Overview and implications

“…Biofortification is the method of increasing the nutrient levels in plants through agricultural, agronomic, T A B L E 2 Summary of enablers and barriers to mandatory food fortification with zinc based on the information from key informants of 10 low-and middle-income countries (Tarini et al, 2021)…”

“…A recent report from Tarini et al (2021) has established the enabling and impeding factors that impact the inclusion of Zn in the fortification of wheat or maize flour in 10 low‐middle‐income countries (Table 2). For this survey, the authors have chosen six countries (Guatemala, Cameroon, Haiti, Malawi, Indonesia, and Togo) where Zn is present in their fortification standard, and five countries (Guatemala, Mali, Burkina Faso, Philippines, and Cote d'Ivoire) where Zn is not present in standard; in that Guatemala was classified in both the groups owing to their policy of Zn fortification for only maize flour and not for wheat flour.…”

Estimating the cost and cost‐effectiveness of adding zinc to, and improving the performance of, Burkina Faso's mandatory wheat flour fortification programme

“…Based on this evidence, the recently updated 2022 WHO wheat flour fortification guidelines include the conditional recommendation to fortify wheat flour with zinc as a public health strategy to improve serum/plasma zinc status (World Health Organization, 2022 ). However, of the 40 LMICs for which zinc deficiency is a public health problem, only 17 include zinc in their mandatory fortification standards (Global Fortification Data Exchange, 2022 ; Tarini et al, 2021 ; K. R. Wessells, personal communication, December 1, 2022).…”

“…In 2012, in accordance with the regional West African Economic and Monetary Union (UEMOA) fortification standard that was subsequently made mandatory in all eight member countries, Burkina Faso implemented legislation mandating the fortification of domestically processed and imported wheat flour with iron and folic acid (Global Fortification Data Exchange, 2022 ; Grant et al, 2018 ). However, despite the estimated high burden of zinc deficiency in the country, zinc was not included in the fortification standard because, at the time the regional standard was developed, there was considered to be a lack of evidence of the efficacy and effectiveness of zinc fortification (Tarini et al, 2021 ). As such, and because wheat flour is already required to be fortified with iron and folic acid, revising the wheat flour fortification standard in Burkina Faso to also include zinc may be a relatively straightforward and low‐cost strategy to increase dietary zinc intakes.…”