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Copenhagen Consensus Center

Micronutrient Fortification and Biofortification Challenge

The Challenge

Undernutrition – when the human body does not get the nutrients it needs for health and survival – remains a major issue in developing countries, and is an underlying cause for between 3 and 5 million deaths each year. Eighty percent of the world’s undernourished children live in South Asia and sub-Saharan Africa.

Micronutrient deficiency is often called ‘hidden hunger’. It attracts less attention than the obvious starvation of people who are unable to get enough food to survive. It refers instead to the sickness that affects people who can only afford cheap, filling food that is deficient in essential vitamins and minerals.

A familiar example of micronutrient deficiency is in a family who can only afford to eat cheap rice, but not the fruit, vegetables and meat that would provide a balanced diet.

When people lack vital micronutrients, they can become weak, sick, and even die. It can affect the immune system and hold back learning and development in children.

Certain micronutrients – including iodine and iron – are very important for development.

Iodine deficiency is the primary cause of preventable mental retardation and brain damage. It is more prevalent in women than in men, and more common in pregnant women and adolescents. Because iodine can be found in seafood, deficiency occurs particularly in inland areas.

Severe iodine deficiency in pregnancy leads to serious and lasting effects for infants. Most children born to iodine-deficient mothers appear normal but have brain damage. The most extreme outcome is cretinism, where the child has almost no chance of a healthy, productive life. Deficiency during a pregnancy increases the risk of infant mortality, miscarriage, and stillbirth.

Iodine deficiency also leads to goiter, an unsightly swelling of the thyroid gland. Although goiters are usually painless, a large goiter can cause a cough and make it difficult to swallow or breathe.

An estimated 2 billion people worldwide have inadequate intake of iodine.

Iron deficiency affects mental ability. It interferes with normal brain development and learning. Children with adequate iron intake can interact better with others, have better cognition, perform better in school, and therefore have the potential for lives with higher incomes.

Iron deficiency in pregnant women is associated with increased risks in childbirth, causing more than 20 percent of maternal deaths in Asia and sub-Saharan Africa and more than 20 percent of the deaths in the first week of life.

Iron deficiency affects one-in-three of the world’s population.


The Solution

A problem as widespread as micronutrient deficiency requires more than just one set of solutions or interventions to have an impact. Two solutions are presented here, which can be considered different ways of achieving the same objective:

Micronutrient Fortification
Micronutrient fortification means deliberately ensuring there are more essential vitamins and minerals in a food product. It is particularly relevant to the problems of iodine and iron deficiency, because these micronutrients can be cheaply and effectively added to basic food products like flour and salt.

Biofortification means developing nutrient-rich versions of the staple crops that poor communities already eat. It can involve ‘genetic modification’.

Micronutrient fortification and biofortification are both food-based approaches, but the interventions are at very different stages: micronutrient fortification has been used with great success for decades (particularly in fortifying salt with iodine), while very few biofortified crops have been released.


The Research

Micronutrient fortification of basic food items with iodine and iron is an incredibly cheap, simple intervention that saves lives. 

Iodine deficiency has already been successfully tackled in many countries with the implementation of the Universal Salt Iodization program, where salt is fortified with iodine. Just one teaspoon of iodine, consumed in tiny amounts on a regular basis over a lifetime, is sufficient to prevent deficiency. 

Thanks to this program, more than 60 nations have iodine coverage of more than 70% of the population. However, nearly one-third of households in the developing world still do not consume iodized salt. There are 41 million unprotected infants and newborns. 

In ‘Micronutrient Fortification’, a Best Practice Paper for the Copenhagen Consensus Center, Sue Horton et al. suggest that the urgent tasks are reaching countries without national programs (this includes many nations of the former eastern Europe/USSR bloc, and sub-Saharan Africa), and increasing coverage to hard-to-reach populations in other nations. 

Iron fortification of wheat and maize is a sustainable and cheap strategy to reduce iron deficiency. Currently only about a third of flour from large mills is fortified with iron; the goal is 80%. Even this will not be enough: wheat and maize flour from large mills reach a smaller proportion of the world’s population than salt does, so Horton et al. suggest that the fortification of other condiments and rice needs to be considered to reach more people. 

Horton et al. estimated the costs and benefits of delivering vitamin A and zinc supplements by region. They found that the annual cost of scaling up salt iodization to reach 80% of the population of South Asia and Sub-Saharan Africa would be .05 per person, or $19 million in total. This would result in benefits per year worth $570 million. The annual cost of scaling up flour iron fortification to reach 50% of the population of South Asia and Sub-Saharan Africa would be .12 per person, or $167 million in total. This would result in benefits per year worth $1336 million.

Getting these micronutrients to the hard-to-reach last 20% of the population is likely to be more expensive, but the benefits (from improved lives and incomes, and reduced costs on healthcare systems) could be proportionally higher. 

Because biofortification works at the level of each individual crop plant, it can serve to reach rural populations not easily served by interventions such as supplementation (see Vitamin A and Zinc) and micronutrient fortification. About 75% of the poor live in rural areas, and have limited access to supplements. The Micronutrient Initiative expects that coverage of fortified foods in rural areas may not exceed one-third.

Research has been conducted into boosting the nutritional content of many different crops. For example, a high-zinc rice is being developed for release in Bangladesh. Orange sweet potatoes rich in pro-vitamins A have been released in Uganda. Research is currently under way to examine the feasibility of introducing nutrients into cassava, sorghum, banana and rice. 

In ‘Biofortification’, a Best Practice Paper for the Copenhagen Consensus Center, J.V. Meenakshi found that for a biofortification strategy to be successful and cost-effective, three issues must be addressed. First, plant breeders must succeed in finding crop-lines with high micronutrient content that can be bred into local varieties. Second, the nutritional effectiveness of a biofortified crop must be established. Third, both farmers and consumers must accept the new variety and make it an important part of what they produce and consume so that it becomes a cost-effective intervention. 

Meenakshi notes that this third issue is currently the biggest factor for the success of this intervention. The greater the share of a country’s food supply that is biofortified, the higher the magnitude of improvements. But this depends on acceptance from farmers and consumers of changes to crops. However, in contrast to Europe where opposition to modified foods appears entrenched, consumer attitudes are not as negative in the developing countries that could benefit most from biofortification. 

The one-time cost of a biofortified crop variety can yield benefits to the local population, year after year. There are virtually no recurring costs, except those involved in maintenance breeding. These of course vary, and are estimated at about $100,000 per year in Bangladesh and $2 million per year in India. In comparison, both micronutrient fortification and supplementation involve recurring costs. 

The benefits from biofortification vary, depending on the crop used and how it is improved. Research, though, shows that this is a very effective investment. Meenakshi examined the costs and benefits of providing zinc-dense rice to Bangladesh, iron-dense beans to Rwanda, and pro-vitamin A maize to Kenya, and found that benefits were between 20 and 200 times higher than the costs, when all of the effects on a community’s health were taken into account.

The ability of biofortification to make a substantial impact varies depending on coverage, which depends on factors like whether there is well-developed infrastructure to support seed dissemination. In most cases, though, it appears highly cost effective and can reach a broad coverage helping disadvantaged communities obtain more diverse, nutritious diets. 


Where to Find Out More

The Copenhagen Consensus research that this section draws from:

Micronutrient Fortification (Iron and Salt Iodization): Best Practice Paper
Sue Horton, V. Mannar, A. Wesley

Biofortification: Best Practice Paper
J.V. Meenakshi

Hunger and Malnutrition: Copenhagen Consensus 2008 Challenge Paper
Sue Horton, H. Alderman, J.A. Rivera

Hunger and Malnutrition Chapter  
in Global Crises, Global Solutions, second edition
Edited by Bjorn Lomborg

The Expert Panel's joint explanation for their rankings is available for download here. The Expert Panel's individual rankings and further elaboration can be found in the book, Global Crises, Global Solutions, second edition.