Inter-agency collaboration to remind all that fortification is a critical weapon in the fight against COVID-19 and long-term development of countries

May 2020
By Karen Codling

During this unprecedented COVID-19 crisis, representatives from several international non-governmental organizations (NGOs) and UNICEF working on food fortification in the Asia region highlighted the importance of maintaining support for the routine fortification of staple foods with critical vitamins and minerals. The objective was to ensure that national governments remain committed to the implementation of mandatory food fortification, and that it should be protected and maintained as an essential service.

Upon hearing about possible threats to national mandatory food fortification programs in the context of national lock downs to prevent the spread of Covid-19, national and regional staff from the Global Alliance for Improved Nutrition (GAIN), UNICEF, Nutrition International, the Iodine Global Network, the Food Fortification Initiative, and the Indonesian Nutrition Foundation for Food Fortification spontaneously and urgently collaborated to prepare a note for policymakers The group was able to confirm from private sector partners that suppliers and distributors of fortificants, the nutrients added to fortified foods, were able to continue operating despite national lock downs in much of Asia, and that many food producers are able and willing to continue fortifying staple foods. The group recognized an opportunity to highlight the importance of mandatory food fortification in the midst of the COVID-19 crisis and developed an article, which is an excellent example of what can be achieved when working together and the importance and benefits of collaboration.

Fortification of staple foods is a critical weapon in the fight against COVID-19

Ravi Menon, Jee Hyun Rah, Sri Kusyuniati, Karen Codling, Becky Tsang, Penjani Mkambula, Sri Sukotjo, Atmarita

The COVID-19 pandemic has engulfed the world.

Health care systems all over the world have been stretched to unprecedented levels, and health care workers have become the world’s heroes as they work to contain the epidemic under significant personal risk. Governments all over the world, including throughout Asia, have put into place measures to persuade citizens to stay at home in an attempt to slow the spread of the disease and reduce infections and deaths from the pandemic. Measures include closure of businesses, requirements to work and stay at home and restrictions on domestic travel. As a result, families have been separated, incomes reduced, unemployment increased, and people are having difficulty in obtaining basic necessities.

The COVID-19 pandemic has dire implications for nutrition. Even before the pandemic, Asia contained nearly half of the individuals, worldwide, suffering from the triple burden of malnutrition, characterized by the coexistence of undernutrition (stunting and wasting), micronutrient deficiencies and overweight and obesity. The determinants of this triple burden are complex and likely to be further compounded by the pandemic. Widespread poverty, unemployment and low education negatively affects household food security and limits accessibility, availability and affordability of healthy food items. These challenges may provoke a surge in malnutrition among the most vulnerable populations.

Good nutrition is critical for the functioning of the immune system and protects against diseases. The WHO guidance during the pandemic highlights that “good nutrition is crucial for health particularly in times when the immune system may need to fight back” While more data is needed on the role of nutrition in reducing the severity of COVID-19, the role of micronutrients to the optimal function of immune systems is well established.

Fortification of staple foods is a safe, very low-cost, effective, evidence based public health strategy to ensure that everyone, including the most vulnerable, has access to essential micronutrients. Successful examples in the Asian region include the mandatory addition of multiple micronutrients to flours and cereals, vitamins to cooking oil and iodine to salt.
Fortification can improve immunity and prevent infections and prevent nutritional deficiencies that increase mortality, constrain educational attainment and work productivity and increase the risk of birth defects. While women and children benefit in particular because they have the highest requirements for micronutrients; all members of the population benefit from fortification of staple foods. This is true especially for lower income populations who cannot afford micronutrient-rich foods and supplements and whose intake of vitamins and minerals is mainly from fortified food.

Disruptions to food systems due to COVID-19 are expected to negatively affect access to fresh and perishable foods due to farmers inability to produce or distribute, resulting in less diversity of nutrient rich foods on the market. We therefore anticipate a rise in consumption of non-perishable foods, which are a poor source of micronutrients. However, consumption of fortified staple foods such as cereal flours, cooking oil and salt and use of these fortified foods in production of processed foods such as instant noodles and bread will mitigate these negative effects.

Our agencies are partners working with Governments to support and strengthen large-scale fortification programs and we are committed to doing all that we can to ensure that the production, distribution and consumption of fortified foods does not falter. The first step is to ensure production and distribution of fortificants (the micronutrient(s) added to foods during the fortification process). We have reached out to fortificant manufacturers in countries with fortificant manufacturing factories (India, China, Germany) and distribution hubs in Asia (Malaysia, Singapore, Thailand) and have confirmed that stockpiles of fortificants are adequate, though lockdowns at some ports has resulted in inevitable delays. However, difficulties in delivery of fortified foods have been encountered due to the limited operations of local haulage suppliers and increases in transport costs especially for small and medium scale producers.

Governments can help ensure the continued production and availability of fortified foods by:

1.	Ensuring that fortificants for food fortification are prioritised for clearance at ports or at border sites.
2.	Exempting fortificants from import duties, taxes, levies and other government-imposed chargers to counter increases in the cost of fortificant due to falls in the value of many currencies as the result of COVID-19.
3.	Clarifying that logistics suppliers for the food industry are essential service providers and enabling access to information and shared economies on spare haulage capacity wherever that exists.
4.	Mitigating the delays in fortificant supplies by putting in place policies for national stockholding of fortificant to ensure local availability and access by fortified foods producers.
5.	Ensuring fortified staple foods and condiments are distributed in social safety net programmes, to mitigate against potential rise in micronutrient deficiencies for vulnerable populations.

ASEAN populations are already going through much hardship during the pandemic. Many will rely on public distribution and social protection schemes that distribute fortified food. Enabling citizens to flatten the curve is vital from both a public health and economic perspective, and continued supply of fortified foods will ensure that a rise in micronutrient deficiencies will not add to the morbidity and mortality toll from COVID-19.

About the authors:

Ravi Menon is Indonesia Country Director of the Global Alliance for Improved Nutrition (GAIN), Jee Hyun Rah is Chief, Nutrition of UNICEF Indonesia, Sri Kuyuniati is Indonesia Country Director of Nutrition International, Karen Codling is Regional Coordinator South East Asia of the Iodine Global Network (IGN), Becky Tsang is Technical Officer of the Food Fortification Initiative Asia, Penjani Mkambula is Global Programme Lead, Food Fortification at the Global Alliance for Improved Nutrition (GAIN) London, Sri (Ninik) Sukotjo is Nutrition Specialist at UNICEF Indonesia and Atmarita is a Nutrition Specialist and Senior Researcher at the Indonesian Nutrition Foundation for Food Fortification (KFI). We thank Jonathan Gorstein (IGN) and Mduduzi Mbuya (GAIN) for their inputs.