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2. Implementing diet- and food-based approaches

2. Implementing diet- and food-based approaches

Diet and food-based approaches play an essential role in presenting micronutrient malnutrition by increasing the availability and consumption of micronutrient-rich foods. In the long-term, such approaches are more likely to be sustainable. However, the benefit of such approaches is not immediate. If overt micronutrient malnutrition (xerophthalmia, goitre or cretinism, or severe iron deficiency anaemia) is present, short-term supplementation programmes should be implemented in addition to starting food-based activities.

In rural areas, major food-based efforts will likely be on horticultural programmes. In urban settings, there is generally better overall food availability as well as the potential for access to fortified food products. It is still beneficial to promote home gardens in pert-urban areas. No matter what location, nutrition education activities strengthen and complement efforts to enhance availability micronutrient-rich foods.

2.1. Increasing small-scale production of micronutrient-rich foods

Any programme that increases the production of micronutrient-rich foods is likely to have a beneficial effect on the micronutrient status of a population. The implementation of such a programme requires that certain conditions such as water availability, appropriate fertile soils, and seeds and seedlings of satisfactory quality are met. It also requires a strong commitment by the agricultural extension service to disseminate techniques of small-scale fruit and vegetable production. This implies that agricultural training and extension programmes. and research institutions pay sufficient attention to these foods. Produce from home gardens may be consumed primarily by the family or sold, partially or entirely, to commercial markets in large urban areas. The produce may also be sold for export. When existing demand for fruits and vegetables is not met by the available supply, the result is higher consumer prices. The poor suffer more from this market situation because they are less able to afford the higher prices, nor can they afford expensive animal products.

2.1.1. Small-scale-community vegetable and fruit gardens

Community and family vegetable and fruit gardens play a significant role in increasing small-scale production of micronutrient-rich foods. Hoogerbrugge and Fresco (1992) define the home garden as a small-scale, supplementary food production system by and for household members that mimics the natural, multi-layered ecosystem. Indigenous gardens have been a part of household production systems since the beginning of agriculture and remain important for food supply, nutrition and income in both industrialized and developing countries (Soleri et al. 1991). Likewise, FAO states that "the home garden is an important land unit for households as it is often the center of family life; a well developed home garden is a complete farming system; the home garden is the most direct means of supplying families with most of the non-staple foods they need year-round (FAO 1995).


Home gardening is well developed in population-dense Asian countries. In Sri Lanka, for example, over 80 % of farms and approximately half of non-farming house-holds have home gardens. Traditional Asian home gardens tend to have large numbers of plant species, in some cases between 100 and 200 (Hoogerbrugge and Fresco 1992). Planners should be aware that much local knowledge and experience already exist in such settings; introduction of new ideas should be well justified and sufficient time should be allowed for them to be widely accepted.

Small-scale gardening projects have proven successful when the following resources are available:

To central governments or outside agencies accustomed to providing all of the inputs for development projects (as is necessary when imported technology or isolated top-down and sectoral approaches are pursued), this may seem like a daunting list of requirements. However, when activities are based on home gardening, participation by large numbers of villagers is encouraged and information is shared, most needs will be met at no external cost.

Many constraints or limiting factors can be identified simply by asking villagers why they do not practice more gardening. Other reasons will emerge during project implementation, which underlines the importance of careful qualitative project monitoring in the early years. If central governments or outside agencies can identify and assist in overcoming these constraints, local participation and responsibility will usually be stimulated.

Land and water limitations may require local government intervention or assistance. One solution to land constraints is to encourage community plots and the growing of vegetables as intercrops where possible, that is, mixing vegetables among trees or staple crops (Harwood 1976). Treeplanting efforts can focus on varieties whose fruit and leaves can be consumed, such as drumstick (Moringa spp.), okra (Hibiscus spp.) and baobab (Adansonia spp.)

In many areas, provision of good-quality seed may require capital input, long-term technical intervention at the national level, or both. Fencing needs will depend on the types of animals (fowl, burrowing animals, or large wild or grazing animals) that constrain gardening. Trees and bushes can be planted to serve as "living fences"

If gardens are begun with indigenous crops, most of the necessary technical knowledge will already exist among villagers. In many countries, women's and farmers' groups have successfully cooperated on gardening projects. Agricultural extension agents may be attracted to assisting with such projects; however, there may be a need to strengthen their knowledge of horticulture.

To have an impact on micronutrient malnutrition, gardening projects must lead to increased consumption of micronutrient-rich foods. A nutrition education component should therefore be linked to such projects. For gardening projects to be sustainable, participants in the projects need to be able to sell some of their produce and save part of this money to cover future expenses.

Group gardening projects have several benefits. Bulk buying reduces unit costs for seed, fertilizer and pesticides. Participants can more easily attract attention and assistance from agricultural extension and other sources of expertise and assistance. Many problems can be resolved more efficiently. For example, if there is a need to keep large animals out of gardens, a group may be able to share the cost of fencing in a large area with good-quality fencing materials. Participants can take turns caring for each other's children at the garden site. A group may be better able to lobby for land close to a water source or for the siting of a new bore hole near the garden or be eligible for obtaining credit from a bank.

Individual plots should be allocated within the community gardening area, with harvests benefiting the laboring families. However, because each individual or family benefits from being associated with the group, it is important that all participants contribute a portion of their earnings to cover group expenses such as the purchase of seed, fencing and fertilizer.


Management of community gardens requires some knowledge of bookkeeping and other simple management techniques. Before expanding to larger-scale production, small-scale gardeners will usually need to increase their understanding of marketing. If too many perishable fruits and vegetables are marketed at the same time, prices will collapse on local markets.

This risk can be reduced if many crops with different harvest times are grown and if both early and late crop varieties are promoted. Knowledge of and access to preservation and storage techniques and improved transport to more distant markets are also often required. Demand for micronutrient-rich foods can be increased through both social marketing and commercial advertising.

2.1.2. School-based gardening programmes

School-based gardening programmes can be an excellent means of introducing new ideas about gardening and a useful channel for reaching others in the community, as children tend to be more open than adults to the adoption of new ideas. School-based programmes can reduce micronutrient malnutrition by:

For school gardening to be successful, at least one teacher in each school needs to be trained in gardening techniques and someone needs to be able to care for the garden during school vacations. Students can do some of the work in school gardens. For sustainability, however, projects should be designed in a way that inspires and empowers students to do gardening on their own at home. It is also important to instill in students the notion of sharing the harvest according to the amount of work invested in it. Exhibit 2.1 describes successful school gardening projects promoted by the Asian Vegetable Research and Development Centre.

Exhibit 2.1. Successful Gardening Promoted Through Schools

The Asian Vegetable Research and Development Centre (AVRDC) demonstrated success in raising vitamin A-rich vegetables in small gardens which were either located at schools or promoted through schools (Llemit and Lastimosa 1988).

A model school garden project in Taiwan developed a 10 x 18 m school garden that provided half a cup of vegetables per day for each of 142 children throughout the school year, using indigenous plants. Each garden consisted of 12 raised beds that over the course of the year contained four or five vegetables. Garden produce provided an estimated 58% of the daily vitamin A requirement and 285% of the daily vitamin C requirement for a 10-year-old child.

2.1.3. Issues to consider in planning community gardening programmes

If planned and designed with a good understanding of local circumstances, gardening is an effective food-based approach to improving micronutrient status. A variety of micronutrient-rich crops can be grown by making use of available space, soil, water and microclimates. As discussed in the previous sections, gardening can be promoted at the household or community level or at schools. The following are important issues to consider in planning small-scale food gardens.


Resources should be directed towards areas where the overall or seasonal shortage of micronutrient-rich foods is most severe. Groups with land and gardening knowledge should be encouraged to cooperate with those who lack these resources. In some places, community-owned land can be used to set up a small-scale garden. In others, access to private land can be negotiated in return for a share of the harvest.

When the major constraint to the implementation of a gardening strategy is a shortage of water, direct approaches undertaken to improve water availability should be complemented by efforts to develop or increase the efficiency of food marketing systems, especially in seasons of fruit and vegetable shortage. Preservation and storage technologies can also be emphasized.

Choice of crops

When the purpose of gardening is to increase micronutrient intake in the diet of vulnerable groups, nutrition and local food habits should be predominant considerations in the selection of crops to promote. Programmes should be capable of adaptation to local soil and climate conditions and to the perceived needs of the local community.

Ideal qualities to strive for in selecting crops for small-scale gardening programmes should be perennial; produce seed of reasonable quality for several years; require minimal labor, land, water, fertilizer and pesticide; be in high demand in local markets; have stable local prices; be capable of storage or processing for offseason use and sale; and have multiple uses, e.g., providing shade, compost, fuel, fibre, fodder, "living fence" pharmaceuticals, or serving as a natural pest repellent. (Bear in mind, however, that no single crop will have all of these characteristics.)

Beginning by growing a small number of key micronutrient-rich foods will reduce start-up time and expenses and require less management expertise to purchase inputs and train participants for each crop grown. It is advisable to begin with hardy crops that need little time or knowledge to grow, process and prepare for consumption.

More productive and higher-value micronutrient-rich foods can be introduced gradually, with greater focus on off-season crops (bearing in mind that cultivation of off-season crops may be limited by access to water, seasonal work burdens, pests and other constraints). Crops that take a long time to bear fruit, such as mango, should be included.

Growing of foods favored by children (e.g., yellow varieties of sweet potato and pumpkin and green leafy vegetables such as amaranth and kang kong) should be encouraged where practical. Production of foods that are eaten frequently may be desirable even though these foods may contain only small amounts of micronutrients. For example, some varieties of potatoes and other root crops contain small amounts of vitamin C, but because they are consumed in large quantities and together with iron-rich foods like green leaves and legumes, their effect on iron absorption is significant.

Papaya, usually liked by children, grows quickly and produces during much of the year. However, as with all foods, simply increasing production of papaya may have little impact on the vitamin A status of children in poorer families because small growers often sell all their harvest. In some areas this is compounded by the habit of cooking papaya before it is ripe, when its carotene content is much lower. Papaya is easily destroyed by storms or floods because its roots are shallow; for this reason, access to new seedlings must be maintained. When investing in papaya for nutritional purposes, hybrid varieties with high levels of beta-carotene (which are generally darker in color) should be chosen.

Increased production and consumption of a few foods which are high in vitamin A or vitamin C (e.g., guava, wild fruit and berries) should also be encouraged. Consumption of foods rich in vitamin C, which enhances iron absorption, and those with a high fat content (e.g., peanuts, avocado, nuts, seeds and soybeans) enhances absorption of pro-vitamin A. Vegetables which contain high levels of tannins should be avoided because tannin inhibits iron absorption. (See Exhibits 3.1 and 3.2 for lists of plant foods that are good sources of pro-vitamin, iron and iodine.)

Community participation

Programmes that promote small-scale production of micronutrient-rich foods can mobilize communities by appealing to community members' perceived needs (e.g., to increase food supply or generate income) in addition to offering to improve nutritional quality of the local food supply. Resource-poor households will be more motivated to participate in programmes that are focused on the needs of people like them who have little or no access to land. Involvement in well-managed programmes. can empower local populations, enhancing their self-confidence and belief that problems can be solved through community efforts.

Women are often more interested than men in working in such community projects, and their involvement can improve their income and social status. Even more important, children's nutrition benefits the most when women retain control of income generated by community projects (Engle 1993).

Overcoming constraints

It may take several years to achieve a critical mass of the knowledge and experience required for a successful gardening programme focused on the production of micronutrient-rich foods. In the early years project monitoring must be intense; additional capital and specialized technical knowledge should be available when needed. Exhibit 2.2 describes successful, innovative gardening projects in several countries.

Exhibit 2.2. Examples of Successful Community Gardening Projects

South India: Papaya saplings, drumstick trees and amaranth seeds were distributed to mothers of preschool children, up to 30% of whom were landless. Local agricultural officers demonstrated how to plant and care for the trees and beds of amaranth. The gardening demonstration project raised the women's awareness of the significance of vitamin A-rich foods in their children's diets. Amaranth grew best under local conditions but was the least preferred of the three crops (George et al. 1994).

Thailand: Successful home gardening requires selection of vegetables suitable to the consumers. A small (36 m²) garden can accommodate 32 kinds of vegetables at once, producing enough to meet a family's daily consumption needs. Gardening year-round, a Thai family can grow up to 48 different vegetables, a mixture of perennials and annual tropical vegetables (Lavapaurya 1994).

Zimbabwe: A decentralized community project evolved from an unsuccessful health sector initiative that originally encouraged peanut production. By allowing the community to decide which crops to grow, taking into account factors such a water needs and fencing requirements, and permitting individually owned plots in addition to communal gardens, the project was turned into a success. An agricultural extension organization provided training in horticulture for its own agents, who in turn helped the community gardeners. Intersectoral committees were formed at national, provincial and local levels to allocate limited government funds (Tagwireyi and Greiner 1994).

Taiwan: The AVRDC vitamin A demonstration gardens successfully produced vitamin A-rich vegetables with low-input practices. The calculated daily yield from 4 x 4.5 m plots consisting of three raised beds was 1.5 kg of edible vegetables per day. For a family of five, this represents over 200% of the vitamin A requirement, along with 110% for iron, over 400% for vitamin C, 81% for calcium and 21% for protein. The gardens were planted in an intercrop manner with spoon cabbage, amaranth, water convolvulus, mustards, shallots, garlic, tomatoes, kale and spinach. AVRDC has been transferring this technology to local communities for their use (Gershon 1985).

India: Vegetable gardens (10 m plots) planted for a harvest sequence of spinach-fenugreek-safflower-dock-amaranth-dill-amaranth-spinach provided well over 100% of the recommended daily allowance for a family of five. Harvesting the leaves early in the day and eating the leaves within 3 hours after harvest provided the highest beta-carotene intake (Josh) and Aralkar 1994).

Bangladesh: Twenty-five per cent of the families in districts served by the Worldview International Foundation's Nutritional Blindness Prevention Programme are totally landless and another 25% own too little land to be self-sufficient. The following innovations were developed to provide these families with access to micronutrient-rich foods:

    n Women volunteers distributed to every household seeds for three types of foods that grow on vines - bottle gourds, yellow fruit (pumpkins) and beans - all of which have commonly eaten leaves. The vines grow up the sides of houses or up trees, enabling produce to be grown on limited land.

    n Groups were formed, composed of four women with land and five women without land. Agreements were negotiated whereby the landless women did most of the labor on the other women's land and received most of the harvest. The women who owned the land received free produce; composting and fencing increased the value of their land.

Vietnam: In an effort to diversify the Vietnamese diet, an integrated ecosystem was established with the acronym VAC, which is drawn from the Vietnamese words for garden (vuon), pond (ao) and animal husbandry (chan nuoi). The integration of practices in these three related areas allows the residue from one activity to be used as fertilizer for another. The establishment of VAC systems at both the family and the community level has significantly enhanced the largely rice-based Vietnamese diet. VAC activities contribute to the overall vitamin and mineral density of participants' diets, especially to vitamin A and iron intake, as well as providing protein and dietary fat. Based on traditional Vietnamese culture, VAC is well accepted, sustainable and cost effective (Tu and Duong 1986).

The level of available capital at startup and the years needed to achieve sustainability will determine how problems are solved. Access to credit is often of crucial importance. Low-cost approaches can be appropriate, although they may be labor intensive and require special knowledge. For example, rotating crops and using natural pesticides can effectively control pests, and composting can be the best approach to the long-term improvement of soil fertility.

Programme monitoring

Continuous programme monitoring is important to ensure that activities are carried out as planned and to ascertain if a project's objectives are attained. Exhibit 2.3 describes a successful home-gardening monitoring project. Talukder et al. (1993) suggest using the following indicators to determine how well vegetable production is progressing.

Exhibit 2.3. Monitoring Demonstrates the Succes of a Home Gardening Project

In Bangladesh, Helen Keller International (HKI) used bimonthly monitoring and a mid-term evaluation to demonstrate the success of a home gardening pilot project combined with a nutrition communications effort. The project increased household availability and consumption of carotene-rich fruits and vegetables. HKI expanded the project into the Non-Governmental Organization (NGO) Gardening and Nutrition Education Surveillance Project, which institutionalized home gardening in the hands of local NGOs.

The dietary and health status of a cohort of children was monitored longitudinally. Variables measured included the percentage of households cultivating at least six varieties of vitamin Arich plants, average per capita consumption of these foods and the prevalence of night blindness in children from these households. The availability of quality seed was found to be a crucial component of success. The project is now developing a way to ensure an adequate supply of quality seeds (Talukder et al. 1994).

USDA/USAID (1987) prepared a document evaluating home garden projects which lists indicators such as measuring economic benefits, nutritional benefits and nutrient costs.

2.1.4. Small animal, poultry and fish production

Small animals (e.g., rabbits, goats and guinea pigs), poultry and fish can make key contributions to micronutrient intake, mainly because of the higher absorption of iron and vitamin A from these foods. Some animals and fish offer income-earning opportunities and also provide important by-products. Fish ponds, for example, provide water for gardening and can also be used to raise ducks.

In most traditional settings, ownership of large animals serves as a form of capital accumulation. Slaughter and sale are not regularly practiced for nutritional purposes but rather for feasts or to meet acute cash needs. The raising of small animals may be a new concept in many areas and may require substantial educational input. For small animal, poultry and fish production to succeed, adequate systems of preservation, storage and marketing must be in place and food safety and hygiene concerns must be a high priority.

The costs of the production and consumption of small animals, poultry and fish can be a major constraint, especially among the poorest and most vulnerable population groups. The population may be inexperienced in production methods and lack access to local expertise in animal and fish nutrition and health. Substantial assessment and training efforts are frequently necessary to overcome these constraints.

2.2. Increasing commercial production of micronutrient-rich foods

Planners often pay less attention to the commercial production of micronutrient-rich foods because the rural poor, who are often considered the major target group for nutrition interventions, usually consume limited amounts of commercially produced foods. Government authorities concerned with the commercial sector are generally unaware of nutrition issues.

Efforts should be made to encourage preservation techniques for fruits and vegetables, such as jam making (for home use and for sale), tomato paste and juicing.

However, micronutrient deficiencies can occur in all income groups, although they tend to be greater among the poor. Efficient, large-scale commercial vegetable and fruit production can supply micronutrient-rich foods at reasonable prices to groups in the cash economy, especially urban consumers. Efficient commercial food production, possibly linked to a food fortification programme, may lower prices for some essential foods that even the poor purchase, such as dietary oils, salt and sugar. Commercial production may also provide employment for landless and other impoverished people.


2.2.1. Horticultural products

Horticultural products (fruits and vegetables) are increasingly being commercialized in many developing countries. They often provide high financial returns per hectare for fertile soils located near large markets. New export markets and growing urban markets enable improved economies of scale.

Small producers can benefit from these developments by gaining better access to high-quality hybrid seeds, chemical fertilizer, pest control and plant protection products and appropriately trained and oriented agricultural extension and field research services. Because horticultural products are so perishable, the commercial sector is dependent on quality control in grading, an adequate transport infrastructure and the availability of proper packaging materials and cold storage. Efficient and competitive markets lower prices for the consumer without reducing the producer price.

2.2.2. Oil seeds

Increasing the production of low-cost dietary fat is a priority in many developing countries. Greater availability of low-cost dietary tat contributes to micronutrient nutrition by reducing protein-energy malnutrition and increasing absorption of vitamin A, especially beta-carotene. In many countries, oil seed production is a major means of increasing production of low-cost dietary fat. Several types of oil seeds have edible leaves. Planting of oil seed as an intercrop can be encouraged, where appropriate, in the commercial or large-scale production of rice, wheat and sugar cane.

2.2.3. Palm oil

Mesocarp oils from several palms are orange in color and, depending on how they are processed, contain high levels of beta-carotene. This so-called red palm oil also contains high levels of vitamin E, which confers stability on the beta-carotene. In some countries, red palm oil production may facilitate improvement of the vitamin A status of key population groups while simultaneously producing dietary fat, a commodity that can earn much-needed income for farmers and traders. Although several years are required from planting to first harvest, a year-round harvest will then be possible for about 30 years.

Red palm oil is most effective at overcoming vitamin A deficiency when the price can be kept low. The palm tree is often grown commercially on plantations, but small farmers can have one or two plants and use the fruit in soups and stews. Farmers must have access to inexpensive land that is well suited to palm oil cultivation. The labor input in planting is low, but the effort involved in picking, transporting and crushing fruits may be high and may pay poorly. More advanced technology reduces labor costs and ensures economies of scale.

Processing equipment is available at various levels of technology. To keep costs down, red palm oil is sometimes transported in large drums and sold to the customer in existing containers such as beer bottles. Low-technology harvesting, production and storage result in a product which goes rancid rather quickly. Under these circumstances, transport and marketing facilities are usually inadequate to encourage widespread use. The advanced technology allows the fresh red palm oil fruits to be sterilized, which ensures longer shelf life.

Crude red palm oil has a distinctive color and odor. In areas where it is a traditional resource, it is preferred over clarified oils. In other places, people may prefer clarified oil; however, refining the oil usually results in loss of nearly all of the beta-carotene. If unrefined red palm oil is introduced as part of a vitamin A programme, it may have lower status than other oils, and thus be self-targeting to the poor who cannot afford other oils. The cost-effectiveness of this approach is untested and probably varies enormously according to local circumstances.

An advantage of red palm oil is that the fat necessary for beta-carotene absorption is automatically present. Yet substantial beta-carotene can be obtained from using red palm oil only if it is not used exclusively for frying at high temperatures for long periods, which destroys the beta-carotene.

In the past, Tanzania required all government-supported schools, prisons, institutions and canteens to use red palm oil in food preparation. This ensured a market for the producers and provided improved nutrition for those eating in these facilities. However, forced consumption may have created aversion to the product among many groups.

Another approach is to use communication channels such as the mass media, schools and health centers to encourage the use of red palm oil much as cod liver oil was previously used in developed countries in Europe and in the United States. About half a teaspoonful of red palm oil a day will meet a child's vitamin A requirements and is affordable for almost everyone.

2.2.4. Beverages

Fruit juices can make a substantial contribution to vitamin C intake, and thus to iron status, as they become widely available and accepted. Carrot and other vegetable juices contain beta-carotene. In some African countries, traditional lactic-acid bacterial fermented beverages, which can be beneficial for iron absorption, are being commercialized. Many of these beverages are nonalcoholic; others are consumed in the early stages of fermentation before alcohol is produced.

2.2.5. Natural nutrient supplements

Leaf protein concentrate (LPC) is becoming available in several countries as a feasible means of greatly increasing dietary beta-carotene intake. It can be used as a nutrient supplement in soups, drinks and baked goods (Pirie 1987). LPC may also contain high levels of iron, but research is needed to determine whether the iron is bioavailable; high levels of calcium are also present, and ascorbic acid (vitamin C) is lost during LPC processing.

Spirulina algae are now being used as a nutrient supplement in India and China. Unlike the leaves used to produce LPC, algae can be sun-dried and still maintain high levels of absorbable beta-carotene (Annapurna et al. 1991). It is probably the only plant food that provides useful and reliable amounts of vitamin B-12. It can be used in small but nutritionally useful amounts in many types of foods without leaving any objectionable color, taste or smell. LPC production also results in a byproduct (the extraction cake) that can be used for animal feed.


2.3. Maintaining micronutrient levels in commonly eaten foods

2.3.1. Improving food storage and preservation

Because many crops are seasonal, harvest surpluses are often lost without the use of adequate processing and preservation techniques. Post-harvest losses can be especially high for micronutrient-rich foods, which tend to be perishable. After a few days of storage, green vegetables lose substantial amounts of vitamin C and carotenoids; refrigeration results in some loss of these nutrients. However, carotene levels in yellow vegetables may increase during storage (Kahn and Fargue 1992).

In commercial trade, these storage losses can be reduced by improved processing, packaging, transport and cold storage facilities. At the household level, practical and often neglected methods exist to increase year-round access to micronutrients. In most dry areas, leaves (and sometimes pumpkins and other fruits) are preserved by drying. Improved technologies such as solar driers may improve the nutrient content in dried products and retain higher quantities of carotene than are retained by traditional methods of drying (see Exhibit 2.4). The cost for a family-type solar drier may be as low as US$ 10. Beta-carotene levels are well preserved in dried fruit, which is popular and is currently being commercialized in some countries, using simple packaging.

Exhibit 2.4. Solar Drying - A Technology for Preserving Vitamin A In Foods

A review of projects in Haiti, Niger and the Dominican Republic concluded that solar drying of beta-carotene-rich fruits and vegetables is an appropriate low-level technology for preserving these sources of vitamin A. The solar-dried foods retain high levels of beta-carotene activity for as long as 6 months. In these projects, members of local women's groups were successfully trained to perform drying tasks (food preparation, drying, storage and marketing) and to aid in the development of culturally appropriate recipes, including instant soup mix and complementary food mixtures, for home consumption. The women's group also marketed the dried products to generate income. Solar-dried fruits are particularly attractive as a source of vitamin A for children (Linehan 1993, Linehan et se. 1994, Jefremords 1995).

Solar driers are being developed and tested by the Tanzania Food and Nutrition Centre. One model, affordable by women's groups, consists of a black polyethylene sheet stretched over a box on wooden legs. The black sheet filters ultraviolet light, which destroys carotenes. Leaves are placed in a drawer inside the box, with ventilation below. Sun heats the box from above. In about 4 hours, amaranth leaves are dry and ready for storage in plastic bags or traditional clay pots with lids. It is estimated that constructing the model of bricks would reduce its cost by one third, making a drier affordable for a family. The drier is suitable for drying green leafy vegetables, mangoes, papaya, pumpkins and yellow/ orange sweet potatoes (Mgoba et al. 1993). FAO has developed a simple mud brick solar drier for sahelian countries. (See Exhibit 2.5.) A training manual covering how to build the drier from local materials and how to use it is available (FAO 1996).

2.3.2. Improving food safety

Food analysis and food quality control systems ensure that processed and marketed foods are of good quality and are safe from chemical residues, adulteration and other possible sources of contamination. They also ensure the quality and safety of micronutrient-rich foods on the market, especially foods fortified with one or more micronutrients. The role of the food industry is important in this respect. Governments should establish laws and regulations on food quality control and should inspect food production facilities to ensure that the required standards are enforced. Both the food industry and the government can establish information campaigns to raise awareness of health problems that may arise from improper food storage and food-handling practices.

Exhibit 2.5. “Instantized” Sweet Potato Powder Tested In Guatemala

Sweet potato grows well throughout Guatemala, though its consumption is limited. An "instantized" sweet potato product with high pro-vitamin A activity is being produced industrially. The product is being tested for acceptability and recipes are being developed for its use. An intensely orange experimental variety could provide 700 IU of vitamin A (or 7000 retinol equivalents) per 30 9 serving. If the powder is found to be acceptable and widely marketed, an inexpensive source of vitamin A could have a public health impact on vitamin A deficiency (Lopez et al. 1993).

Food control systems are also necessary to facilitate international trade. This may be particularly important for the trading of iodised salt and other fortified foods. Adequate nutrition labelling, including proper packaging and limit dates for consumption, should be promoted and enforced to ensure the quality and micronutrient content of packaged and fortified foods.

2.3.3. Better food preparation in the home

Food preparation methods are culturally and economically determined and should be approached with care and respect. When new foods are introduced into the diet, as occurs with urbanization, there is a greater need for information on food preparation in the home.

Frying and fermentation decrease levels of beta-carotene in foods by about 25%; vitamin C is destroyed by cooking. Losses of both beta-carotene and ascorbic acid are greatly reduced when vegetables are placed in boiling water and cooked for the minimum time necessary. Steaming in a covered pan preserves nutrients even more effectively. Because vitamin C and iodine are water soluble, they are sensitive to losses caused by throwing away cooking water (iodised salt is commonly added to food during cooking rather than at the table, where less loss would occur).

2.4. Plant selection and breeding to increase micronutrient levels

Because the levels and bioavailability of micronutrients in foods such as sweet potatoes, squash, plantain, green leafy vegetables and tomatoes vary greatly, it is possible to select varieties of these crops that contain higher levels of beta-carotene or vitamin C. Some hybrid varieties of tomato, mango and papaya have several times more beta-carotene than other varieties. The United States Department of Agriculture has bred carrots with triple the normal level of beta-carotene. A quarter of a good-sized cooked carrot of this type will provide enough vitamin A activity for a child for one day. Production and taste tests have already been successfully conducted in two dozen countries.

Although some research in plant selection and breeding has focused on crop varieties with high levels of iron or zinc, scant attention has so far been paid to opportunities for increasing micronutrient levels in commonly eaten foods, particularly staple food crops. Many questions must be answered before large-scale investment in plant selection and breeding for nutritional purposes is possible, namely, cost, time scale, yield, consumer acceptance and bioavailability. Improving the micronutrient content of soils can result in improved yields as well as increased micronutrient content in the crops produced with such soils. Research on plant breeding and soil enhancement for nutritional goals should be given greater priority on the development agenda.

2.5. Food fortification

Food fortification - one of the food-based strategies for preventing micronutrient malnutrition - is the addition of nutrients to commonly eaten foods to maintain or improve the quality of a diet. A fortification programme is usually undertaken in response to dietary, biochemical or clinical evidence of nutrient need. Fortification should be viewed as part of a range of measures that influence the quality of food, including improved agricultural practices, better processing and storage methods and consumer education.

Several terms used in discussing food fortification require definition. Enrichment or restoration is the addition of nutrients to a food to compensate for the loss of nutrients during processing. Fortification is the addition of nutrients at levels higher than those found in the original or comparable food. Food technologists frequently refer to fortification as nutrification. The food that carries the nutrient is the vehicle; the nutrient added is the fortificant. Multiple fortification is the addition of more than one nutrient to a single food vehicle.


Fortification of foods with vitamins and minerals is not new. Early in this century, table salt was iodised in Europe. The concept of nutrient fortification of staple foods was developed in the 1930s and 1940s as a result of the discovery of vitamin deficiency diseases. A general consensus was reached that fortification of widely used and economically priced food was desirable. Programmes were endorsed by the United States and some European countries to enrich wheat flour and other grain products with iron and B vitamins, as well as to fortify some dairy products with vitamin D and vitamin A (reveille 1984).

In developed countries, where dependence on processed foods is high and industries are streamlined and automated, fortification has played a major role in increasing the dietary intake of micronutrients. Analyses of nationwide food consumption data have shown significantly increased intake of various micronutrients by various age-sex groups in the United States as a result of fortification and enrichment practices (Cook and Welsh 1986). The role of food fortification in virtually eliminating micronutrient deficiencies in developed countries is widely acknowledged and recognized (Bauernfiend and DeRitter 1991, LaChance and Bauernfiend 1991, Hoffpauer and Wright 1994, Wiemer 1995).


In developing countries, fortification is increasingly recognized as an effective medium- and long-term approach to improving the micronutrient status of large populations. Fortification does not require changes in the dietary habits of the population, can often be implemented relatively quickly and can be sustainable over a long period of time. It is considered one of the most cost-effective means of overcoming micronutrient malnutrition (World Bank 1994).

2.5.1. Planning and designing a fortification programme

Fortification programs require careful planning to ensure that appropriate food vehicles and fortificants are selected to enhance micronutrient status in the target population. It may be difficult to ensure that groups which consume lower levels of the fortified foods receive adequate quantities of the added micronutrient.

The cost-effectiveness of fortification is dependent on consumption patterns within the population. Fortification may not be an appropriate intervention because of the absence of a suitable food vehicle to reach the vulnerable population, difficulty in enforcement of fortificant requirements or high cost. Determining where food products are fortified is important and must take into consideration the geography and food distribution system of a specific country or a whole region involving several countries, as in the case of salt iodisation programmes.

Exhibit 2.6 describes the key elements of successful food fortification programmes. Exhibit 2.7 lists the steps to be followed in developing a fortification strategy. Exhibit 2.8 lists the key players in food fortification programmes.

Exhibit 2.6. Key Elements of Successful Food Fortification Programme

1. Policy Support

    Fortification needs to be incorporated into permanent nutrition policy to protect it from temporary changes in political or economic situations. Experience has shown that awareness by decision makers and the public of the extent, severity, and the possibilities for controlling micronutrient malnutrition within a short space of time has been an important factor in generating political will to support fortification efforts.

2. Feasibility and Safety

    It must be established that fortification can efficiently combat identified micronutrient deficiencies without negative effects on prevailing food production and distribution processes. The fortification process must be technically feasible and the fortified food acceptable to consumers. Population groups targeted for fortification should consume the food selected for fortification in amounts sufficient to ensure that adequate levels of the nutrient will be obtained without risk of toxicity.

3. Multiple Sector Involvement

    The planning and implementation of food fortification programmes requires the active involvement of the industry, trade, planning, transport, regulatory, communication and education sectors to effectively integrate fortification into the food production and distribution system.

4. Economic and Marketing Incentives

    The food industry is a key player in food fortification programmes. Educational, financial and marketing incentives should be used to overcome any initial reluctance by food producers to cooperate with fortification efforts. Financial incentives may be particularly important in the crucial initial period during which consumer demand for fortified products is being created.

5. Information, Education and Communication

    Information, education and communication (IEC) campaigns educate consumers and generate demand for fortified food. The social marketing approach enhances IEC by focusing on consumer perceptions and attitudes.

6. Monitoring of Micronutrient Levels

    Monitoring and evaluation systems should be in place to ensure the continuous presence of required levels of the micronutrient levels throughout the production and distribution system.

7. Sustainability

    A formula for sharing the cost of fortification among government, industry, and consumers should be agreed at the outset. It should be ensured that, given the cost, the fortification programme is sustainable. Even a small price differential between the fortified and unfortified product may jeopardize the programme's success.

8. Food Regulatory System

    Programmes need to be supported by a food regulatory system that includes enforcement procedures for noncompliance with specified standards for food quality, packing, labeling and required micronutrient levels. Enforcement has proved critical in ensuring the quality of iodised salt, especially in countries with large numbers of small producers.

Although fortification may be effective without consumer education, it is generally considered wise to include a consumer education component, if only to avoid the spread of rumors and incorrect information. Education may also be required when the fortified product requires different handling during household storage and when certain cooking or product use practices result in loss of the fortificant. Iodised salt, for example, is more effective when used as table salt than when used in cooking. Some people may be accustomed to washing impure salt before using It; if salt of this. kind IS iodised, consumers must be educated not to wash it because washing will remove all the iodine.

Exhibit 2.7. Steps in Developing a Fortification Strategy

    n Determine the micronutrient status of the population (see Section 3.1).

    n Identify patterns of consumption of potential food vehicles among key target groups.

    n Choose an appropriate food vehicle and fortificant.

    n Establish the stability and acceptability of the fortified vehicle.

    n Assess the bioavailability of the micronutrient from the vehicle in the appropriate dietary setting.

    n Undertake a controlled field trial.

    n Implement a regional or national fortification programme.

Food vehicles used for fortification may not be foods for which increased consumption is desirable (i.e., salt). Thus, while striving to ensure that consumers choose fortified foods, promotional programmes should avoid approaches that will lead to overconsumption.

Exhibit 2.8. Key Players in Fortification Programmes

To be successful, fortification programmes require the active collaboration of five key groups.

    n The scientific community, which has identified both the problem of micronutrient malnutrition and a possible solution - fortification of a variety of foods.

    n National governments, which must provide the regulatory framework and administrative support for the implementation of fortification programmes.

    n Consumers, who need to be educated about the benefits and low cost of food fortification to create a demand for fortified products to which the food industry must respond.

    n International and bilateral aid agencies, which may play a coordinating role and also provide initial funding for fortification programmes.

    n The food industry, which has the ability to create economically viable fortified products that are affordable, safe and wholesome.

2.5.2. Selection of food vehicles

Selecting a food vehicle for fortification involves identifying a food that:

Table 2.1 lists foods that have been fortified with Vitamin A, iron and iodine in developing countries. Programme planners should refer to technical reviews for further information on specific compounds and levels (INACG 1993, Dunn and van der Haar 1990, Nestel 1993). Bauernfiend and Brooke (1979) provide a full treatment of food fortification methods and equipment.


Vitamin A






Wheat flour


Brick tea



Infant formulae

Corn flour











Whole wheat



Wheat flour





Corn meal





Wheat flour noodles






Fish sauce


Curry powder


Maize meal






Food vehicles for vitamin A

In the 1970s, several Central American countries, including Guatemala, El Salvador and Honduras, passed laws requiring that sugar produced for home consumption be fortified with vitamin A. This resulted in a significant reduction in the proportion of pre-school children with serum retinol levels below 20 g/dL (Arroyave 1979,1982, Arroyave et al. 1981).

In many countries, margarine, hydrogenated oil and shortening are fortified with vitamin A palmitate or other esters and/or a carotenoid such as beta-carotene, which acts as both a coloring agent and a nutrient. Oils used in light cooking or salads can also serve as carriers. For deep-frying oils, a high-stress beta-carotene suspension is available which contains antioxidants to retard carotene loss. In India, it is mandatory for a hydrogenated cooking fat product called Vanaspati to be fortified with vitamin A. In the Philippines, Star margarine was fortified with vitamin A. (See Exhibit 2.9.) Trials conducted in India and Pakistan established the technical feasibility of fortifying tea with vitamin A.

Exhibit 2.9. Vitamin A Fortification of Margarine in the Phillippines

Fortification of Star margarine with vitamin A involved an unprecedented collaboration that involved the product's manufacturer, The Procter & Gamble Co., agencies of the government of the Phillippines, research institutions, the National Nutrition Centre of the Philippines and Johns Hopkins University in the United States (Solon et al. 1996).

As recommended by experts in the Philippines, the margarine was fortified according to a formula that provided 375 9 retinol equivalents of vitamin A per 15 mg serving. Evaluation demonstrated that vitamin A was stable during storage and usage and had no effect on the taste or appearance of the product.

The Nutrition Centre of the Philippines, in collaboration with Johns Hopkins University, conducted a double-blinded, placebo-controlled study in Cavite Province to determine the efficacy of the vitamin A-fortified margarine. Children aged 3-6 were randomly assigned to receive either fortified (n=353) or unfortified (n=350) margarine for 6 months. Results of the study showed that consumption of vitamin A-fortified margarine significantly increased serum retinol values. In addition, children who consumed the fortified margarine developed no clinical signs of vitamin A deficiency.

After reviewing these data, the Department of Health of the Philippines awarded the vitamin A-fortified Star margarine an official product acceptance seal for use on the product label.

Food vehicles for iron

Fortification with iron is technically more difficult than fortification with other nutrients. Requirements for iron fortification include the following:

Reducing the global prevalence of iron deficiency anaemia will require the use of several alternative fortification compounds and food vehicles, depending upon local dietary patterns.


In industrialized countries such as the United States and Canada, cereal-based foods have had significant success as vehicles for iron. Fortification of milled cereal staples has also been adopted in countries such as Belize, Grenada, Haiti, Jamaica and Venezuela. The objective is to restore the iron lost through milling. In these countries, consumers do not have the choice of purchasing the unfortified food at a lower cost. Most retailers and consumers are not even aware that the products are fortified. Ferrous sulphate is the most common form of iron used in milled cereals such as wheat and corn. In products likely to be stored for a long time before consumption, however, reduced iron is preferable because of its greater chemical stability although its bioavailability is low. Elemental iron of small particle size is being used in North America to fortify processed cereals.

Rice is considered a possible vehicle for iron fortification because it is the staple food of more than half the world's population, including people in many countries where nutritional anaemia is highly prevalent. Despite many attempts, however, no large-scale rice fortification effort has been successful in developing countries. In the 1950s, a law was passed in the Philippines requiring mills to fortify rice by mixing in grains coated with thiamine, niacin and iron. However, consumer acceptance of the fortified rice was poor. Early monitoring of the experiment revealed that when consumers cleaned the rice they picked out the fortified grains, which were a different color. A large-scale media programme was launched to encourage acceptance of the new rice. Unfortunately, the programme was abandoned because of the difficulty of enforcing the law requiring rice fortification (Florentino R. in INACG 1990).

Technical requirements for the fortification of salt with iron are much more stringent than for the fortification of salt with iodine. Over the past two decades, iron fortification of salt has been accomplished in India and other countries, and trials in Thailand and South Africa have shown encouraging results. Further efforts are needed to ascertain the effectiveness of double fortification (with iron and iodine), which seems to be a promising tool for future interventions.

Sugar is an attractive vehicle for iron fortification in regions where it is produced in only a few facilities. However, in many developing countries, consumption of refined sugar favors middle and upper economic groups.

In Thailand, fish sauce consumed in many parts of the country has been tested as a food vehicle for iron; fish sauce fortified with NaFeEDTA has shown good haemoglobin response. Fish sauce and fish paste have been used as vehicles in the Philippines. Curry powder fortified with NaFeEDTA produced marked improvement in haemoglobin and iron stores in an Indian population in South Africa. In Chile, chocolate cookies have been fortified with dried haemoglobin for distribution as part of a school lunch programme; they are now sold commercially (Walter et al. 1993).

Food vehicles for iodine

Since the 1930s, several methods of supplementing dietary iodine have been proposed to eliminate iodine deficiency disorders (IDD). A variety of food vehicles have been tried, including salt, bread, sweets, lactose and water. Iodisation of salt has become the most commonly accepted method of iodine prophylaxis in most countries of the world. Its advantages include uniformity of consumption, universal coverage, acceptability, simple technology and low cost. Permanently establishing the iodisation of salt in a country eliminates IDD. There is now a global commitment to virtually eliminate IDD by 2000; to reach this goal, several countries have succeeded in reaching the goal of universal iodisation of salt by 1995. Criteria have been established for assessing the adequacy of salt iodisation programmes (UNICEF 1995).

2.5.3. Industry participation in food fortification

Throughout the world, the food industry plays a critical role in fortification. In marked contrast to the situation in the developed world, developing countries are grappling with fundamental issues of providing adequate food supplies to feed their expanding populations. Simple nutritional and technological solutions to the problems of micronutrient malnutrition exist, but they are often complicated by economic, social and political factors, and intervention strategies must take these factors into account. This is the challenge as well as the opportunity facing the food industry.

In particular, the food industry (both national and multinational) needs to:

2.5.4. Determining the cost of fortification

In addition to the cost of the fortificant, which is usually the predominant recurrent cost of a food fortification programme (see Table 2.2), the following elements contribute to the cost of establishing a fortification programme: man power and utilities, equipment maintenance, quality control, administrative overhead, packaging and amortization of plant costs.

Table 2.2. Costs of Selected Fortificants




Cost (Range) US$/caput/year



Potassium iodate

50-80 ppm I2

.03-.05 (1990)



Potassium iodate

20 ppm I2

.12-.15 (1990)



Ferrous sulphate

1000 ppm Fe



Vitamin A

50,000 IU/kg

.30 (1991)


Cooking fat

Vitamin A

50,000 IU/kg

.30-.40 (1990)


Wheat flour

Ferrous sulphate

29-44 mg/kg




(based on 430 g flour/person/day)


The cost of potassium iodate is about US$0. 10/tonne for every 10 ppm iodine in salt. Therefore for iodine content in the range 30-100 ppm, the fortificant cost would be US$0.30-1.00 per tonne of salt, or US$0.001-0.003 per person per year. Fortifying salt adds from 5% to 10% to the retail price of salt.

The cost of iron fortification depends upon the type of iron compound and dosage, which in turn is linked to iron content and bioavailability. (See Table 2.3.) On the basis of a recommended dietary intake of 12 mg/day, the cost of iron compound varies from US$0.02 to US$0. 10 per person per year. The use of stabilizers adds a variable amount to the total cost. In Guatemala, fortifying sugar with iron added only 1-2% to the cost of the sugar (Nester 1993). Experience in India showed that iron fortification could add 40-50% to the retail price of salt. The cost of the food vehicle is generally low compared with the price of the fortified food.


Fe %

1990 Cost US$/kg

Cost US$/kg Fe




Hydrogen reduced iron




Fair -



Electrolytic iron




Fair +



Ferrous sulphate







Ferric ortophosphate







Ferrous fumarate














Liquid (oily) vitamin A palmitate (300 mg retinol/g) and dry vitamin A palmitate (75 mg retinol/g) cost about US$46-58/kg in 1997. On the basis of a recommended dietary intake of 850 g of vitamin A per lactating woman, the cost of vitamin A is around US$0.015 per person per year. Vitamin A could add significantly to the price of food; it accounted for 89% of the cost of the Guatemalan sugar fortification programme (Nester 1993).

The cost of food fortification must be either subsidized by the government or carried by consumers as an increase in the price of the food. Programmes are often initiated with subsidies, with costs being passed on to consumers in a phased manner over several years. During the subsidy phase-out period, financial incentives may be offered to the food industry to minimize the price differential between fortified and unfortified products. In the case of salt iodisation, these incentives might include the free supply of potassium iodate for an initial period and the provision of free iodisation equipment, orientation and specialized training. In some countries, food producers may offer tax incentives for an initial period to enable them to establish fortified foods in the market.

When contemplating increasing the price of a food, policy makers need to consider elasticity, that is, the percentage change in consumption that may occur for each percentage increase in the price, as well as the percentage change in the consumption of one food when the price of another is increased.

To reduce the burden on the poorest groups, whose need for the micronutrient is the greatest, countries should explore the feasibility of targeting subsidized fortified food to these groups while spreading the cost across all fortified food sold in the country. Another strategy is to focus on foods which are selectively consumed by low-income or high-risk groups, including food distributed through ration shops, work programmes, school feeding programmes and mother-child health clinics. In Tamil Nadu, India, ironfortified salt is used in all foods prepared for schoolchildren as part of the state's noon meal scheme.

The micronutrient needs of populations receiving imported food aid should be considered in relation to the commodities received and their intended use. Various processed cereals, oil and blended food supplements used for food aid are fortified and enriched with vitamins and minerals. Nonfat dry milk powder should always be fortified with vitamin A. Enrichment and fortification practices and levels vary by donor (see Section 5.5).

2.5.5. Quality assurance and control

The main objective of any food fortification programme is to ensure that, at the time of consumption, the food vehicle contains the specified amount of the micronutrient. The rate at which the micronutrient is retained depends on the fortificant, the type of packaging, the exposure of the package to prevailing climatic conditions and the time that elapses between fortification and consumption. Exhibit 2.10 lists the factors associated with successful salt iodisation programmes and describes the difficulties associated with packaging and transporting iodized salt.

Exhibit 2.10. Factors Associated with the Succes of Salt Iodisation Programmes

The success of an iodisation programme depends upon the following factors:

    n identification and assessment of the IDD problem;

    n awareness of and support for salt iodisation by policy makers and the public;

    n universal iodisation of all salt for human and animal consumption;

    n strong commitment to iodisation by the salt industry;

    n proper quality control and packaging and a well-planned distribution system;

    n economic and marketing incentives for salt producers;

    n enforcement that ensures compliance with regulatory standards;

    n regular monitoring of salt iodine levels and periodic evaluation of the programme’s impact on IDD status; and

    n coordination among the health, industry, trade, transport, agriculture and education sectors.

The development and implementation of a quality assurance system is essential to ensure the sustained effectiveness of a fortification programme. The system should guarantee that the food is properly fortified at the production level and reaches the consumer with the required levels of potency and quality.

Fortification may take place within a country or, if the food is imported, in the country of origin. Inevitably, some fortificant is lost between the points of production and consumption. These losses are higher in countries where packaging quality and storage and transportation conditions are inadequate.

Countries should establish expected micronutrient levels at different levels in the distribution system, taking into account climate, type of packaging and per-capita food consumption. Micronutrient concentration should be regularly monitored. At the national level, overall responsibility for quality control of food fortification programmes should be clearly identified; responsibility is frequently vested in the ministry of health, food or agriculture. Criteria for assessing the adequacy of salt iodisation programmes have recently been established (WHO/ UNICEF/ICCIDD 1994). Similar guidelines can be established for other fortification programmes.

Failure to implement and sustain effective quality assurance systems is likely to result in the failure of food fortification programmes. In Guatemala, poor monitoring and regulation of the sugar fortification programme resulted in four levels of vitamin A in sugar for several years after the programme was initiated. Slackening of monitoring of the salt iodisation programme led to a recurrence of IDD.

Exhibit 2.11 lists steps in the implementation of a quality assurance programme for the production of fortified foods.

Exhibit 2.11. Implementation of a Food Fortification Quality Assurance Program

Wilson (1988) identified the following steps in the implementation of a quality assurance program for a fortified food product:

1. Product Specifications

    All specifications for the fortificant, vehicle and any other ingredients must be documented, including particle size, color, potency, level of fortification and any other requirements considered necessary. Acceptable deviations from the specifications must also be documented.

2 Product Safety Assessment

    Microbiological, chemical and physical hazards of all ingredients, as well as of the finished product, must be assessed.

3. Product Analysis

    Procedures for sampling and testing all ingredients, as well as the finished product, must be documented.

4. Determination of Critical and Quality Control Points

    The entire production process (including the plant facility, equipment and environment) must be examined to identify stages ("control points") at which inadequate quality control could adversely affect product quality or lead to an unacceptable health risk. Controls and actions to be taken at each control point must be documented.

5. Recall System

    A mechanism must be in place to recall products if necessary.

6. Quality Assurance Audit

    Periodic checks must be conducted to verify that the quality assurance system is effective and that product quality is maintained up to and including the time the consumer receives the product.

7. Feedback Mechanism

    A mechanism must be in place to correct any product deficiencies identified by consumers or other relevant groups.

8. Documentation

    All steps in the quality assurance system must be documented and readily available to relevant individuals and organizations.

Packaging and transportation of iodised salt

Iodised salt is often consumed in areas far removed from salt-procuring centers. It is therefore important to ensure that the salt retains the specified level of iodine when it reaches the consumer. When iodised salt is improperly packed and transported over long distances in humid conditions (over 76% humidity), it becomes wet and the iodate settles to the bottom of the package. At lower humidity levels, salt can release surface moisture, which may result in some iodine loss. If the salt is packed in porous packaging, the iodine compound can leak out. To avoid these losses, iodised salt must be packed in waterproof bags or containers. For monitoring purposes, salt containers should be labeled with the name and address of the producer and the date of manufacture.

2.5.6. Food regulatory system

In FAO's view, legislation that provides for food fortification in general (enabling legislation) is preferable to separate pieces of legislation for each fortification activity. Such general legislation, which could be an existing public health or food and drug law, authorizes the relevant government department to regulate and determine specifications for food fortification (Nathan 1995). (Major components of a food regulatory system to enable food fortification are listed in Exhibit 2.12.)

Exhibit 2.12. Major Components of a Food Regulatory System to Enable Food Fortification

In FAO's view, the following should be major components of legislation to enable food fortification:

    n authorization to fortify food to address nutritional deficiencies and improve health;

    n designation of the government agency (frequently the ministry of health) with responsibility for issuing specific enabling regulations for each fortification measure (this approach offers the ability to respond promptly to changing requirements); and

    n enforcement and penalties for non-compliance with regulations.

Enabling regulations should cover:

    n foods for which fortification is mandatory or is permitted;

    n the type, quality and amount of fortificant to be added, the minimum levels required at production/port of import, distribution and consumption;

    n labelling specifications; and

    n quality control and monitoring, with designated responsibility and regular mandatory reporting of results.

Such a food regulatory system can be effective only when a monitoring system exists to ensure compliance and penalize defaulters. The monitoring system should be supported by an inspection force that has clearly defined procedures for sampling foods and well-established standards and analytical methods for determining the micronutrient content of fortified foods. Inspectors may be associated with government department (e.g., the ministry of health, supply, industry or commerce) or with a non-governmental organization.

The enforcement and control of a food fortification programme requires trained technical staff as well as procedures and facilities for assaying the levels of nutrients in foods. Periodic checks should be made of the nutrient content of the food at points from production to distribution, at both the retail and household levels.

Ultimately, regulation of a food fortification programme is less important than education which motivates the food industry to comply with standards voluntarily. Consumer groups can play an important role in ensuring that the food industry complies with regulations.

2.5.7. Management and coordination

In addition to a food regulatory system, effective food fortification programmes require adequate technical, operational and financial support for production, marketing and mass education. A national micronutrient advisory body may be needed to devise a master plan of operation and to continually monitor progress in implementation.

The health sector generally plays a vital role as the initiator, coordinator and monitoring agency for fortification programmes. It is imperative, however, that other sectors of government, as well as non-governmental organisations (NGOs), are involved in appropriate activities that promote food fortification.

2.5.8. Monitoring and evaluation

Regular monitoring of food fortification programmes. should continue permanently, even after effective control of micronutrient malnutrition has been achieved. To ensure safe and appropriate levels of fortification, both the production (or input) and household levels of fortificant should be monitored.

The success of a fortification programme depends on ensuring that the specified micronutrient content is monitored at the consumer level. When a problem is identified, rapid, semi-quantitative methods can be used to determine its source. It may be desirable to conduct occasional prevalence surveys of micronutrient deficiency in samples of representative population groups or in specific geographic areas. The surveys should include clinical examinations and, if possible, laboratory determinations of appropriate indicators. Fortification needs to be sustained to achieve observable changes in micronutrient status.

Where possible, monitoring should directly involve consumers. Countries such as Bangladesh have encouraged NGOs and schools to use low-cost iodine field-test kits to monitor salt iodisation. This has helped to heighten awareness and encourage community participation. In Ecuador, it has proved useful to ask schoolchildren to bring salt from home for testing.

Overall progress towards sustainability in food fortification might be measured by the degree to which a programme maintains or improves control of micronutrient malnutrition and decreases its dependence on external support. Exhibit 2.13 describes activities and strategies that can enhance progress.

Exhibit 2.13. Strategies to Sustain Fortification

Political: Major factors that determine the political sustainability of fortification programmes are the commitment of government and private groups to the elimination of micronutrient malnutrition. Political sustainability in turn ensures effective regulation and enforcement, which ensures compliance by the food industry. In some parts of the world, universal salt iodisation would require increased regional cooperation to standardise salt quality iodine levels, packing and labelling.

Social: Awareness of the importance of overcoming micronutrient deficiencies and creation of sustainable consumer demand for fortified products rely heavily on communications strategies for modifying attitudes and practices among both consumers and the food industry.

Technical: Important technical factors are the development of indigenous capacity for project and programme design, supply, training and quality control.

Financial: Financial sustainability is achieved when funds are available to ensure the continued availability of the human and material inputs necessary to maintain programme achievements, with an increasing reliance on local resources. One strategy for accomplishing the phased transition of costs from donor to internal resources might involve the donor covering capital costs of facilities without paying much for maintenance, continued training and other costs. Donors may also help design more effective methods and procedures and thereby reduce recurrent costs. National governments and consumers should assume recurrent costs as quickly as possible without jeopardizing achievement of goals. The details and timing of the transition of costs are crucial factors. The long-term goal should be to achieve programmes. self-sufficiency. This can be accomplished if industry markets a profitable product which consumers perceive as having sufficient value to justify a minor additional cost. However, fortification is sensitive to foreign exchange availability, which has negatively affected sustainability in some countries.

Managerial: Food fortification programmes require effective management and coordination of activities including epidemiological assessment, advocacy, communications, regulation and quality control, and monitoring and evaluation. Effective collaboration among the health, industry, agriculture and education sectors is also required. Programme management should be supported by adequate funding from the regular government budget.

2.5.9. Marketing of fortified foods

The launch of a fortified food product requires a series of marketing decisions about packaging, pricing, distribution channels, retailing practices and promotion strategies. This process requires close cooperation between technical and communication experts.

The central premise of marketing is that decisions should be guided by consumer preferences, habits and needs, rather than by medical or technological considerations. Each fortified product (for example, iodised salt, flour or curry powder fortified with iron, sugar fortified with vitamin A) creates a unique marketing situation. A consumer perspective is key to assuring demand for and use of the fortified product. A variety of methods are available to assess public opinion, and most countries have universities and other organizations with the capability to conduct consumer studies. The kind of questions that need to be answered in a marketing study are illustrated in Figure 2.1.

Figure 2.1. Research questions to guide marketing decisions




n What are consumer beliefs about IDD, vitamin A deficiency, anaemia, etc.? What are "resistance points" (barriers) to buying and consuming the new product? Are there any "selling points" for the fortified product?



n What do consumers value about the food/food product?


n What are the attitudes towards packaged foods (salt, sugar, etc.)?


n What is the average quantity of the product purchased?



n How often are purchases made?



n What kind of price sensitivity does the product have?



n How is the product stored by the shopkeeper? at home?



n What is the media exposure of the target group?




The introduction of a fortificant into a food product may necessitate special packaging to avoid loss of potency and moisture damage and to distinguish between fortified and unfortified versions of the same product. In countries where salt, sugar and other staples are commonly purchased loose by weight, fortification may necessitate the introduction of packaging, a major change for consumers.

The introduction of packaging when it did not previously exist, or the introduction of better quality packaging, will result the price increases and may require consumers to buy larger quantities of food than they are accustomed to buying. Consumer research can help programme managers to make the right decisions about the type and size of packaging and pricing of the fortified food.

Market research may reveal that consumers will not accept the increased costs created by packaging. Protective, labeled packaging of fortified products may be possible only at the wholesale level when less expensive, unfortified food is available. This will require different approaches to both fortification levels and consumer education, to account for nutrient losses incurred at the retail and household level.


Fortification will increase the cost of the food product. Determining whether the cost of fortification should be subsidized by the government, absorbed by the producer/importer or passed on to the consumer is a key strategic decision. The experience with fortification in the West suggests that fortification programmes have greater long-term sustainability when consumers absorb the cost increase. However, cost studies are needed to ensure that the price does not put the product out of the reach of target groups.

Countries have handled this issue in various ways in response to different market situations. Price elasticity for the food product - which should guide pricing policies - can be assessed by studying household income and expenditure patterns.


If governments find that they must subsidize fortification, targeting becomes important as a cost-saving strategy. To keep costs low, countries have pursued two kinds of market segmentation strategies: selecting for fortification foods that reach a particular income, age, ethnic group or region where need is greatest, and subsidizing selectively through food stamps and ration shops. Targeting can have high nutritional impact at low cost.

Distribution and retailing practices

Retailers, who come into daily contact with consumers can be given training and incentives to help answer questions and promote fortified products. Lack of training in retailing practices, on the other hand, can undermine a fortification programme. In India, market studies found that retailers were not concerned about proper storage: bags of fortified salt were often left open, exposing the product to air (CMCD 1988). Studies in other countries have shown that shopkeepers are not always aware that the salt or sugar they are selling is fortified and thus do not take adequate storage precautions.

Exhibit 2.14 provides examples of marketing decisions made by fortification programmes in various countries regarding packaging, pricing, targeting and retail and distribution practices.

Exhibit 2.14. Food Fortification Marketing Decisions


In India, marketing studies conducted for the salt iodisation programme found that most consumers preferred loose salt because they could buy whatever quantity they wished. However, buyers liked the assurance of quality and safety and the health-related benefits which they associated with packaged products. As a result of these studies, a plan was developed to market both a low-cost product, packaged in simple bags and sold in 200 9 or 500 9 sizes; and an elaborately packaged premium product, offered in 200 9, 500 9 and 1 kg sizes and aimed at higher-income consumers (CMCD 1988). Although this strategy was not implemented, it illustrates one approach to the issue of packaging.


    n In India, the salt iodisation programme found that a dual brand strategy, in which a low-price brand was financed by a higher-priced one, would finance fortification (CMCD 1988).

    n In Honduras, sugar processors were required to absorb the cost of fortification with vitamin A and initially did so. However, when world sugar prices declined and the cost of the fortificant simultaneously increased, fortification stopped. The foreign exchange costs of purchasing the fortificant made this arrangement particularly vulnerable to cost increases (Nester 1993).

    n In Ecuador, the government subsidized iodized salt for several years until consumer demand was strong and the product well established. The cost was subsequently passed on to the consumer.


    n "In the United States, the Women, Infants and Children (WIC) programme, which serves poor families, provides food vouchers to the lowest income group. Among the foods that can be purchased with these vouchers are high-iron cereals which contain 45% of the recommended dietary allowance for iron (compared with 25% in most breakfast cereals).

    n In Sri Lanka, where levels of micronutrient deficiency are highest on tea estates, consideration is being given to fortifying, with iron, wheat flour destined for these estates. According to market studies, the cost of targeted iron fortification would be only 8% of the cost of universal fortification (Nester 1993).

Retailing and Distribution Practices

    n In Bangladesh, distributors and shopkeepers handling iodised salt were trained to protect the product and to handle the gunnysacks full of iodised salt without hooks that would puncture the protective packaging.

    n In Tanzania, a programme was developed to educate retailers about iodine deficiency disorder, answer customer queries and train them how

Promotion of a newly fortified may not always be essential or even desirable

Fortification is an attractive strategy for providing needed micronutrients without requiring consumers to make difficult behavioural changes. Generally, food technology can deliver a product that looks, tastes and smells just like the unfortified version. The consumer benefits nutritionally by consuming the fortified version of the familiar product. Because fortified products are often required to be labeled as containing added nutrients, consumer education or promotion may be required.

Promotion of a fortified food is necessary when

A well-designed marketing strategy can create a consumer preference for a fortified food product and distinguish it from competing products. The fortified product must be creatively packaged, priced, distributed and promoted. Other circumstances that make promotion necessary are presented below.

When non-fortified and fortified products compete, understanding why consumers may choose unfortified food products is the first step in designing an effective promotion strategy. Barriers, or "resistance points", may be attitudinal (the nutritional deficiency is not viewed as serious or its consequences are poorly understood), cost-related (the fortified product costs slightly more than the unfortified version; for the poorest groups, even a few pennies' difference in cost can be significant) or a matter of custom (households accustomed to cooking with rock salt consider that it tastes better than iodised salt or that it has other preferred properties).

Packaging, often to maintain the quality of fortified products, can be used creatively to help consumers distinguish between fortified and unfortified products. Logos can also be an effective advertising tool. In a multi-product environment, a logo can enable the government to support fortified products. Consumers can be encouraged to look for products bearing the "fortified" logo. Logos should be distinctive, simple to reproduce in different formats and easy to convey in radio messages.

Experience to date of promoting fortified products (primarily iodised salt) in developing countries has shown that it is rarely adequate to simply inform people of the specific health benefits of fortification (such as prevention of goitre). Exhibit 2.15 describes alternative approaches that have been used in several countries. Exhibit 2.16 describes a communication strategy that successfully promoted consumption of iodised salt in Ecuador.

Exhibit 2.15. Approaches to the Promotion of Iodised Salt

Studies in many countries have found that goitre is not viewed as a serious problem; few people know that goitre is associated with reduced mental capacity. In a marketing study conducted in India in 1988, people reported that goitre "did not really harm anyone" or prevent them from earning a living. The believed that one of the causes of goitre was bad water (CMCD 1988). Few people knew that iodised salt could prevent goitre. In some countries, women with goitre are considered attractive and mental deficiency is considered to be God's will (Associates for Communication Options 1992).

Successful education programmes to increase consumption of iodised salt have promoted the product on the basis of a thorough understanding of consumer perceptions. This is a three-step process: perceptions about goitre as harmless must be rectified; a link must be established between goitre (or mental impairment) and iodine deficiency; and iodised salt must be promoted as the solution to the problem.

Two approaches have been adopted to creating consumer demand for iodised salt: intensive consumer education about the gravity of iodine deficiency and the importance of consuming iodised salt; and promotion of selling points unrelated to health benefits, such as convenience and freshness.

India: A marketing study concluded that "while building up knowledge may be one route to influencing behaviour, it may not be the easiest route via mass media" (CMCD 1988). The information is complex and the audience may become confused. Marketing specialists were concerned that iodised salt would be seen as a medical, curative solution only for those with goitre. The study concluded that the product should be promoted on the basis of cleanliness and health (features of packaged salt valued by consumers), with such messages as "safe, modern salt (also iodised)" and "the clean, healthful, affordable salt (also iodised)" (CMCD 1988).

Pakistan: iodised salt was successfully marketed as a way of enhancing children's educational capacity. Endorsement of the product by religious leaders and trusted health workers also proved to be an effective strategy. Although anthropological studies found widespread misconceptions about goitre and its causes, the programme did not focus on correcting them (Favin and Griffiths 1991). Products fortified with vitamin A and other micronutrients have also been successfully promoted by highlighting qualities valued by consumers, such as taste and purity, which are not necessarily related to health.

Bolivia: In a country where most salt is not iodised, communication strategies have been credited with reducing goitre prevalence from 65% in 1983 to 24% in 1989. The long-term strategy is to assure an adequate iodised salt supply to remote areas so that local, non-iodised salt is eventually displaced (IDD Newsletter 1991).

Overcoming resistance. Promotion of a fortified food is necessary when consumer resistance or opposition from special interest groups is anticipated. Public information campaigns play an important role in these situations. The product launch is an especially critical period. Labeling of fortified products with the added nutrients, as is required in many countries, can lead to damaging rumors. A common misconception is that fortification causes diarrhoea. Because diarrhoea is so common, some children will contract it after the introduction of any new food. Another common suspicion in some countries is that the fortificant is a contraceptive.

Exhibit 2.16. Ecuador: A Communication Strategy to Promote Iodised Salt

In Ecuador, the population affected by iodine deficiency disorder (IDD) did not perceive the disorder's consequences to be a serious problem. In the 1980s, a stratified communication programme was developed in which the country was divided into three risk areas, defined by consumption of non-iodised salt.

In low-risk areas (where less than 30% of the population consumed non-iodised salty, short radio messages were broadcast promoting iodised salt. In moderate-risk areas (where 30-50% of the population consumed non-iodised salt), 30-second radio spots were broadcast 10 times per day for 3 years. In addition, teachers were trained to conduct salt consumption polls and given support materials that enabled them to discuss the severe impact of IDD on school performance and dispel doubts about the benefits of iodisation. In high-risk areas (where more than 50% of the population consumed non-iodised salt), saturation-level radio messages were combined with intensive training of community leaders to introduce information to the local population through slide shows and visits to markets and fairs.

Community participation was key to the development of persuasive messages. The principal messages conveyed were:

    n Goitre and mental deficiency are diseases.

    n They are caused by a shortage of iodine in food.

    n The easiest way to prevent these diseases is to use iodised salt in food every day.

Consumption of iodised salt increased significantly as a result of this intensive education effort. From 1984 to 1987, 17% of communities were at severe risk of IDD and more than half of the households at risk consumed non-iodised salt. By 1992, fewer than 1% of these communities were still classified as at severe risk of IDD (UNICEF/Ecuador 1993). The longer-term strategy being pursued is to increase salt commercialization and its iodisation.

Some fortification programmes have been halted because special interest groups successfully lobbied against them. Opposition to fortification is believed to be based on concern about replacing conventional foods with products of no nutritional value. Opponents of fortification have argued that nutrients could be added to a nutritious food that lacks harmful characteristics, such as flour or vegetable oil. However, in the areas worst affected by micronutrient malnutrition, nutritious foods are produced locally or by decentralized methods, making them unsuitable candidates for fortification. The few centrally processed products that reach everyone, such as salt, sugar and soft drinks, are the only foods that can feasibly be fortified, and they are likely to be objectionable to some people.

Fortification may also be opposed because vitamin A, iron and iodine can be toxic if consumed in high doses. Planners must make every effort to avoid the use of rare but well-publicized cases of toxicity to fan opposition to fortification programmes. In Indonesia there were objections to the fortification of MSG with vitamin A.

Religious, cultural and other groups have objected to fortification in some countries. The process may be viewed as tantamount to adulteration. In Canada, there were objections to the addition of vitamin D to milk. In the United States, some communities have steadfastly opposed fluoridation of water.

When programme planners consider me planners consider opposition to fortification to have a rational basis, it may be useful to involve the opposition groups in dialogue, expose them to scientific information and invite them to participate in technical studies and help to devise compromise solutions. A broad consumer education programme can help shape public opinion and place extreme positions in perspective.

Other reasons for promoting fortification. Promotion may also be desirable when fortification is an added benefit that can enhance demand for the product or change the pattern of its consumption and when target groups do not consume the fortified food but might be willing to do so if it were promoted.

In many cultures, vitamins and minerals are valued and viewed as especially desirable for children. Consumer perceptions that fortification adds value to a product can be used to build public support for fortification and acceptance of higher prices for fortified products, as well as to increase the number of people benefiting from fortification. However, planners should be aware that increased consumer interest in a fortified product can be exploited to raise the price of the product. Greater consumer appeal that leads to higher prices can result in reduced consumption of the fortified product by the poorest groups.

Several countries have experimented with aggressive advertising of fortified products to increase sales. In the late 1960s the government of India, with support from the U.S. Agency for International Development, fortified bread with Iysine and promoted the fortified product heavily (Parlato 1992). The Swift Company in the Philippines began advertising hot dogs as "vitamin-packed", with endorsements from the health ministry "for taking part in our efforts to eliminate micronutrient malnutrition."

If the food industry finds that improved nutritional quality sells products, it will be motivated to continue offering consumers these benefits. In the United States, fortification is often a commercial selling point. Fortified breads, breakfast cereals and other products have been successfully marketed for over 40 years. (However, advertising claims must be regulated to avoid the making of misleading and false statements.)

2.5.10. Importance of advocacy

Experience in different parts of the world has consistently shown that launching and sustaining a food fortification programme requires political will and commitment. It is probable that more fortification programmes have failed because of waning political support than for any other reason. If politicians do not understand the importance of a programme, they may reduce or eliminate support for it.

However, politicians may not respond to programme success per se; they may require evidence of public support. In the 1970s, several Central American countries began fortifying sugar with vitamin A. After a period of initial success (vitamin A deficiencies were reduced by about 50%), fortification was halted (Dary 1991). There was no political commitment to enforce the fortification law or provide resources to help defray rising foreign exchange costs for the fortificant. After a lapse of several years, these fortification programmes have recently re-started and special efforts are being made to build in mechanisms for sustainability, including effective monitoring, product promotion and advocacy.

A fortification programme must be carefully nurtured from the beginning with a well-defined advocacy strategy. Fostering the commitment of both the scientific community and the food industry to combating micronutrient deficiencies is important. In addition, alliances should be created with NGOs and politically powerful groups who can help to promote food fortification. In Chile, for example, ministries of education interested in the mental development of children have lobbied for iron fortification. Maintaining contact with groups who are potential opponents of fortification can also be an effective strategy.


Special events, regular press releases and briefings of journalists can maintain high visibility for a fortification programme, highlighting its impact and benefits relative to costs. In some countries, gaining recognition that IDD affects intelligence has been crucial. In other countries, computer models that calculate the economic benefits of investment in fortification may be convincing.

Lastly, consumer demand for fortified products is a potentially important force in maintaining political support. Creating and sustaining consumer demand requires highvisibility promotion of fortified products on their nutritional merits. Consumer groups can also serve as watchdogs, helping to monitor the quality and price of the products.

2.6. Using communication strategies to increase consumption of micronutrient rich foods

Agricultural production of micronutrient-rich foods and production of micronutrient-fortified processed foods enhance micronutrient availability. However, achieving increased consumption of these foods may require a change in food habits. Such a change requires a vigorous and concerted effort of all sectors (agriculture, health, education and industry) through a variety of communication channels, e.g., radio/television, print media and interpersonal communications.

There is conclusive evidence that nutrition communication can convey information, help people develop necessary skills and motivate people to make lifestyle changes. Programmes that used audience-centered approaches had a positive effect on nutritional status, even among low-income groups. Most of these programmes used a social marketing or social mobilization approach, including a well-defined process to develop their communication strategy (Parlato et al. 1992).

This section of the manual presents some principles and lessons learned from behaviour-change and communication components of micronutrient programmes in developing countries. It is designed to assist in the realistic and cost-effective use of the scarce resources available for information, education and communication (IEC). The material is applicable both to the promotion of fortified foods and to increasing the production, preservation and consumption of micronutrient-rich foods.

In most countries, important improvements in the micronutrient status of the population can be obtained by changing practices at the household level and by protecting nutritionally beneficial traditional practices that are eroding because of factors such as urbanization and modernization. When incomes rise, people often reduce breastfeeding, stop gathering wild foods and eat fewer green leafy vegetables. Such activities are often considered low status. The mass media can be a powerful force in helping to preserve positive traditional practices by enhancing their status. Exhibit 2.17 describes the nutritional benefits of certain traditional practices.

Exhibit 2.17. Examples of Nutritionally Beneficial Traditional Practices

    n Breastfeeding, especially when sustained for long periods. Breastfeeding provides more vitamin A and fat (for carotene absorption) than any other food available to many rural infants.

    n Gathering of wild, leafy vegetables, which are sources of carotene, iron and vitamin C.

    n Collecting of wild fruits by young children. Wild fruits often have an extremely high vitamin C content. In addition, they increase absorption of iron from other hods consumed at the same time.

    n Lactic acid fermentation of grain, which increases the bioavailability of iron contained in the grain.

Micronutrient deficiencies occur in part because of poor demand for and inadequate consumption of available foods. Supply is rarely the only limiting factor. Better nutrition requires individuals to make sound decisions about what they purchase, grow and eat. Such decisions are generally based on deeply ingrained food preferences and eating patterns.

Communication techniques that draw on principles of advertising, community development, adult education and behavioural psychology have been used for more than two decades to help bring about changes in eating practices. Vitamin A has been the focus of more communication efforts than other micronutrients. Successful communication strategies from many countries demonstrate the importance of carefully planning communication interventions and of basing strategies on information obtained directly from those who are the targets of the strategy, for example, mothers and others who influence food production, purchasing, preparation and child feeding behaviour.

Programmes should aim to reach not only those who prepare families' food and supervise the feeding of children but also those who make decisions and shape opinions about food consumption patterns in the household. In any community, religious, traditional and cultural leaders can influence shifts in food behaviour and sanction new customs. In certain regions, fathers do the shopping and control the money used to buy food. In many cultures, the father decides what food is served in the household and how it is apportioned. For these reasons, targeting messages only at mothers may be ineffective.

It is also important to provide nutrition education for school children, girls out of school and adolescents, as they are future parents and need to be aware of how to maintain or improve their dietary habits.

IEC, can persuade individuals to consume more foods rich in vitamin A and iron, choose fortified foods, prepare foods in new ways to protect their nutrient content and change patterns of feeding children. However, it will take time for changes such as these to become firmly established in local culture. Exhibit 2.18 provides examples of behaviour changes that can increase the micronutrient status of vulnerable members of the population.

Exhibit 2.18. Behaviour Changes That Can Increase Micronutrient Intakes

The following are examples of relatively small changes in food behaviour which can have a significant impact on micronutrient status.

New Skills

    n Solar-drying of green leafy vegetables and yellow fruits and vegetables to extend their season of availability.

    n Preparation of recipes using higher proportions of micronutrient-rich foods.

    n Appropriate household-level preservation methods for fruits, vegetables, fish and meats.

    n Food preparation methods that preserve micronutrients: short cooking times, steaming, adding food to boiling water rather than cold water, and boiling rather than intensive frying.

    n Mashing and, if necessary, straining fruits and vegetables so they can be eaten by infants aged 6-12 months.

New Behaviour (in some countries)

Infant feeding:

    n Feed colostrum instead of discarding it.

    n Breastfeed for 2 years and more.

    n Start giving pureed vegetables at about 6 months.

General eating habits:

    n Consume micronutrient-rich foods more frequently.

    n Include more servings of iron and vitamin A-rich foods in the family diet.

    n Purchase snacks such as grilled liver, nuts and fruits instead of sweets lacking in micronutrients.

    n Add more oil or oil-seed powder when preparing vitamin A-rich vegetables for children.

    n Eat new food combinations to enhance micronutrient absorption, such as fresh fruits with or directly after meals rather than only between meals.

    n Eat the leaves or other parts of foods that are not traditionally consumed.

    n Maintain traditional foods in the diet when they are being replaced with foods that contain fewer micronutrients.

    n Avoid or reduce consumption of tea and coffee with meals.

2.6.1. Identifying motivations for food behaviour

Simply transmitting scientific information on how to recognize micronutrient deficiencies or how vitamins prevent deficiencies is unlikely to change behaviour. To change eating habits, communication programmes must learn what motivates food behaviour by mothers and other key household or community members. These motivating factors are rarely what nutritionists or programme planners assume them to be.

Night blindness, anaemia and other medical consequences of inadequate micronutrient intake which concern public health officials may not be perceived as serious problems by the population. Education programmes often fail because they try to introduce new practices by stressing benefits that local people do not consider important. Pollard and Favin (1990) found that, in Indonesia, mothers' understanding that dark green leafy vegetables (DGLVs) prevented blindness and night blindness "seemed to reinforce the limited value of DGLVs to the diet, as neither health problem was regarded as endemic and night blindness was not particularly serious".

In Thailand, interviews with mothers revealed that they were unconvinced their children could go blind from not eating enough vitamin A-rich foods. None knew of blind children in their villages. However, mothers did express concern about the frequent bouts of diarrhoea and other infections that their children suffered. Programme planners used this knowledge to promote the ivy gourd plant as a way of staying healthy rather than preventing blindness (Smitasiri et al. 1993). In Mali, community studies found that although many pregnant women had experienced night blindness, they did not view it as a serious problem because it usually disappeared after they gave birth (Dettwyler and Fishman 1990).

Understanding the factors that constrain or prevent people from following desirable dietary practices and finding practical and acceptable solutions that overcome these "resistance points" are critical to the success of a communication programme. Exhibit 2.19 describes common barriers to the consumption of micronutrient-rich foods.

Exhibit 2.19. Barriers to me Consumption of Micronutrient-rich Foods

Market factors:

    n Seasonality and cost seriously limit availability of micronutrient-rich foods in many countries. Many programmes underestimate the importance of easy access to the food selected for promotion.

    n Cleaning dirt from vegetables may use a lot of precious water, which is unappealing to women who may have to haul water over long distances. As a result, preparation of these foods may be perceived as more time-consuming.

    n Cost is a prime constraint on the purchase of animal sources of vitamin A or iron.

    n Fruits and vegetables do not substantially reduce hunger and may be perceived as a luxury.

    n Limited choice of vegetables and fruits causes monotony, especially for children.

    n Families who depend on foods purchased at a weekly or bi-weekly market may purchase only enough to last 2-3 days to avoid spoilage.

    n Preparation and cooking time may be (or may be perceived to be) longer for micronutrient-rich foods than for other foods.

Cultural factors:

    n Because most DGLV are inexpensive, they are perceived in many countries as a "poor man's food". This image may be exacerbated by the fact that wild greens are eaten during periods of famine and in the lean season before harvest. In some cultures, the lack of status of DGLV is reflected in their absence from ceremonial meals.

    n Vegetables may traditionally be eaten in small quantities as condiments or sauces rather than as a main part of the meal. Cultural norms and family eating traditions make these eating patterns difficult to modify. In some communities, vegetables are not considered food (only staples are). Therefore different cultural rules apply to vegetable consumption.

Bioavailability factors:

    n Bioavailability of iron from vegetable sources is low in grain-based diets and when high-tannin products are consumed with meals.

    n Carotene absorption may be low in diets very low in fat.

Age factors:

    n Children do not often like many vegetables.

    n Mothers believe vegetables (especially the dark green leafy varieties) are hard for children to digest and cause diarrhoea.

2.6.2. Selecting dietary changes to be promoted

The most important and most difficult step in designing a communication strategy to improve micronutrient status is deciding which food or food-related behaviour to promote. Programme planners can benefit from conducting a rigorous analysis of possible behaviour changes to identify those with the greatest potential. Exhibit 2.20 describes the five key decisions that programme planners must make in developing a communication strategy.

Exhibit 2.20. Key Decisions In the Development of a Promotion Strategy

Experience in the application of communication techniques to the improvement of micronutrient status indicates that programme planners need to make five key decisions when developing a promotion strategy to change food behaviour.

    n What food or dietary changes should be promoted?

    n Who does the message need to reach?

    n How should the message be presented?

    n What communication channels should be used for maximum impact?

    n What resources are needed to implement the effort?

Experience has shown that the most successful behaviour-change projects focus on few small, specific changes. The more general a communication programme, the less effective it is. The smaller the suggested change in existing practices, the better are the chances of it being adopted permanently. To avoid confusing and overwhelming target populations, successful programmes focus on changing one or two key behaviour patterns. (See Exhibit 2.21.) This approach ensures that the message can be assimilated sufficiently to have a lasting effect.

Exhibit 2.21. Effective Communication Strategies

Experience over the past two decades has shown that communication strategies have been most effective in bringing about positive changes in food-related behaviour when they:

    n isolate a limited number of specific behaviours that significantly affect the nutritional status of the target group;

    n propose small behaviour changes that provide a viable choice within the time and cost constraints of the household and larger community;

    n develop different messages for each group of people that influences the target group, using spokespersons, images, sounds and words most meaningful to each group; and

    n convey these messages with enough saliency and for a long enough time that the ideas enter normal conversation and eventually behavior - at the individual or community level.

There is conclusive evidence that nutrition communication can convey information, help people to develop necessary skills, and motivate people to make lifestyle changes. Programmes that have used audience-centered approaches have had a positive effect on nutritional status, even among low-income groups. Most of these programmes used a social marketing or social mobilization approach, including a well-defined process to develop their communication strategy (Parlato et al. 1992).

During the initial assessment phase of a vitamin A mini-project in Niger, a series of actions were identified that would improve vitamin A intake, including preserving the vitamin content of foods by shade-drying green leaves, cooking leaves and vegetables by steaming instead of boiling, using larger quantities of dark green leaves in sauces, eating vitamin Arich foods more frequently, stocking up on vitamin A-rich foods when they are in season and introducing new recipes to boost yellow squash consumption (Keith et al. 1991).

Once actions that would have a high impact on vitamin A intake were identified, project managers worked with local families to select one or two changes that had the best chance of being adopted. Through this process, increasing consumption of leafy green vegetables and liver was determined to be the most promising ways of filling the micronutrient gap.

Market surveys have found that DGLVs are the least costly source of vitamin A and iron in many countries. However, programme managers should not automatically exclude other foods. In Niger, liver was selected because it was the least expensive source of vitamin A during that part of the year when vitamin A-rich foods were most scarce. Fruit is usually a more expensive source of vitamin A than green leafy vegetables, but it is often more palatable to children.

Choosing the best food to promote requires careful consideration of local preferences, costs and cultural factors. Exhibit 2.22 describes product strategies that have been successful in several countries. Exhibit 2.23 describes the process by which a campaign in Indonesia selected foods to promote.

Exhibit 2.22. Examples of Successful Product Strategies

Successful projects have used a variety of product strategies that were based on consumer attitudes and preferences and cultural and market factors.

Thailand: A regional project promoted the ivy gourd plant (Coccinia indica) as a representative of vegetables high in vitamin A. Programme managers felt that intense promotion of one product was the most cost-effective way to attract consumers' interest and positively affect vitamin A status. The ivy gourd plant was selected over three other candidate vegetables that were tested (swamp cabbage, Chinese cabbage and sesbania leaves) because it had the highest vitamin A content and children liked it the best (Smitasiri et al. 1993).

Indonesia: In the SOMAVITA project in West Sumatra, community-level research led managers to focus promotion efforts on dark green leafy vegetables. Messages referred to "green vegetables" instead of the more cumbersome term DGLVs used by nutritionists. Pictures of the most commonly consumed green vegetables reinforced the message. Because research had shown that local people did not perceive blindness caused by vitamin A deficiency to be a serious problem, the campaign instead promoted green vegetables as bursting with vitamins essential for good health. Pictures of smiling, healthy babies were featured. Because karate was a popular sport in the region, posters featured a baby who grew up to be a karate master. The campaign slogan, which was based on a traditional rhyme, stated: "I'm healthy and strong thanks to green vegetables every day" (Pollard 1989). Mothers were encouraged to cook vegetables in coconut milk, hide them in soup and serve them as snacks to make them more appealing to children (IVACG 1992).

Niger: Because studies found a scarcity of affordable vitamin A-rich foods and large seasonal variations in availability, project managers chose one food to promote each season. The featured foods were dried or fresh leaves (for use in sauces); liver snacks (consumed after the harvest when families had cash); mangoes (during the hot season); and kopto, a cooked salad made from dark green leaves. Liver, a so-called luxury item, was chosen because a very small quantity is needed to satisfy micronutrient needs. Target families could afford to buy it two or three times a month as a marketday snack, which was enough to maintain body stores of vitamin A (Keith et al. 1991).

Bangladesh: Mothers in one region responded positively to messages about vitamins in general but not specifically vitamin A and did not perceive the prevention of blindness to be a serious concern. Programme managers promoted dark green leafy vegetables and other prime sources of vitamins, such as sweet pumpkin, as "bursting with vitamins". Mothers were advised to cook and mash vegetables well to avoid diarrhoea and indigestion in young children. Radio programmes and talks at health clinics reinforced this message (Pollard and Favin 1990)

Mauritania: Local people believed that adding green and yellow vegetables to the staple dish of couscous would cause diarrhoea. They were reminded that they traditionally added tomatoes and carrots to their diet without ill effects. Messages focused on how tasty couscous was when green and yellow vegetables were added to it and how eating vegetables ensured healthy and strong children. The campaign also stressed that dirty food and water, not vegetables, cause diarrhoea (IVACG 1992).

The Philippines: The Nutrition Centre of the Philippines used television spots to increase the perceived value of inexpensive and widely available vitamin A-rich foods. Catchy rhymes were used for easy recall. The leaf of the bitter melon (one of three dark green leafy vegetables featured) was compared to carrots, which were already well appreciated for giving "clear eyes, skin as smooth as cream" (IVACG 1992).

2.6.3. Communication strategies to improve micronutrient intake in children

Young children are often a key target group for micronutrient programmes. The younger they are, the more dependent they are on adults to give them an adequate, micronutrient-rich diet. A communication campaign that aims to improve micronutrient intake in young children must be directed at the children's care-givers.

Exhibit 2.23. Indonesia: A Community Strategy

Faced with developing a communication strategy for a national vitamin A programme covering over 13,000 islands and a range of microclimate and food zones, managers of the SOMAVITA Project in Indonesia realized that no one vitamin A-rich food could be promoted nationally. They decentralized research and strategy development to identify one target food in each region, using a common set of research protocols and planning worksheets.

Step 1. A quantitative survey was conducted in three provinces to identify, on the basis of availability and price, the best food sources of vitamin A. Ten foods were identified, including amaranth, cassava leaves, carrots and other vegetables, bananas and other fruits, eggs and liver and other animal foods.

Step 2. A qualitative study examined the acceptability of each of the 10 hods, looking specifically at availability, consumer preferences and perspectives on use and preparation of the foods and household consumption patterns. Project staff also obtained insights from the population about potential difficulties in buying or using the identified foods. Through this process, five of the 10 foods were identified as having the most potential for increased use: amaranth, cassava leaves, papaya, eggs and liver.

Step 3. A series of provincial-level workshops were held to decide which of the five foods to select for promotion. Criteria for selection were:

    n availability,

    n acceptance,

    n current consumption and the likelihood of increasing consumption,

    n vitamin A content and relative impact on vitamin A deficiency,

    n parity with current practices,

    n price and

    n ease or difficulty of preparation and use.

Discussions among nutritionists, social marketing experts and programme managers resulted in the selection of one food to promote in each of two regions: amaranth in West Sumatra and eggs in Central Java. Because mothers in the two regions had indicated that they wanted to be able to feed their children a variety of dishes, it was also decided to promote a series of recipes.

Step 4. Campaign "fine-tuning" activities included identifying and promoting locally used recipes rich in the selected vitamin A food and rapid assessment surveys to give district-level managers a means to evaluate the impact of the campaign (MOH/HKI 1993; Rasmuson, personal communication to M. Parlato).

Such a campaign should be supported by knowledge of which of the locally preferred and available foods for young children should be given most frequently to improve micronutrient status. Specific messages relating to young children's needs and preferences are needed. For example, although children often not like bitter or coarse green leafy vegetables, they may be partial to sweeter, softer varieties. Fruits are also favorites in some settings.

Efforts should be made to dispel care-givers' beliefs that are harmful to children's micronutrient status. A relevant message might be "Green vegetables do not cause diarrhoea if they are cooked properly and served warm with clean utensils". Tips for less time-consuming ways of preparing locally preferred micro-nutrient-rich foods for children may be helpful. Campaigns can also incorporate reminders that micronutrient-rich foods should be introduced in infants' diets at 6 months of age and gradually increased in frequency.

2.6.4. Strategies to increase quantities of micronutrient-rich foods consumed

Although micronutrient-rich foods may be both available and consumed, often they are not consumed in sufficient quantities to prevent deficiencies. Strategies that can increase amounts consumed include persuading individuals and families to eat micronutrient-rich foods more frequently, add more vegetables to a staple food dish such as rice or millet, add a vegetable dish to a meal or eat micronutrient-rich foods as snacks.

The least disruptive dietary change - the one that is closest to present practices or corresponds most closely to the culturally accepted definition of a meal - offers the best chance of success. Some programmes have found that snacks offer the best means of changing established dietary patterns. Typically, communities have fewer cultural proscriptions against or ingrained expectations of snacks, which makes change less difficult. Community members are best placed to help decide which approach to adopt.


Food, essential for survival, is also deeply embedded in culture. Planners must creatively address the challenges posed by established perceptions of what appropriate foods are and what constitutes a meal. In Niger, where leaves are traditionally eaten as a sauce accompanying the staple millet dish, women laughed at the idea of making more sauce, as it would have ruined wellestablished cultural norms of what constitutes a proper balance between food items. Women felt it was more logical to increase family consumption of leaves by eating more kopto, a cold salad of cooked greens traditionally served as a snack (Keith et al. 1991).

2.6.5. Selecting communication channels for maximum impact

Effective exposure of behaviour-change messages requires the integrated use of a mixture of communication channels, including mass media and interpersonal communication. A trained health worker can allay a mother's concerns about feeding vegetables to a 6-month-old. Radio can popularize selected foods and new dishes. Community-level discussions may help leaders to understand and sanction new food behaviour. The nature and complexity of the message and the target populations' pasterns of exposure to mass media will determine the selection of communication channels. Interpersonal communication should be emphasized when complex behaviour change is being promoted.

Recent studies have documented that broadcast media (radio and television) are an extremely cost-effective way to reach large numbers of people. Although the cost of using these media is high, the number of people who change their behaviour as a result of exposure to new ideas on radio or television actually makes this option relatively inexpensive per person influenced (Parlato et al. 1992).

Making daily consumption of vegetables, fruit and other micronutrient sources an accepted, routine practice may take considerable time. A long-term, carefully sequenced communication effort is necessary to achieve permanent change in food behaviour. Typically, individuals will try out new food behaviour when attention is focused on a problem, but they will not persist with the desired behaviour unless repeated messages are provided. Specialists in public health communication have noted the phenomenon of behaviour decay, or reversion to an original behaviour pattern in the absence of periodic reinforcing messages (Parlato et al. 1992). Experience of anti-smoking and fatreduction programmes in the United States indicates that it may take 10 years or more for desired changes in behaviour to become sustained.

2.6.6. Identifying resources needed to implement the strategy

Programmes that aim to change dietary patterns will need to allocate sufficient human and financial resources for the task. Human resources should include a communications coordinator to oversee all aspects of the micronutrient programme and specialized technical staff to implement various phases of the programme.


The financial resources required will vary considerably, depending on how many people are trained and how much media time is purchased. A rough rule of thumb is that 10-20% of overall programme budgets should be dedicated to communication activities.

Several excellent manuals are available on planning, executing and evaluating communication programmes (see Appendix 2).

2.6.7. Monitoring and evaluation

When food manufacturers attempt to change consumer purchasing behaviour by advertising their products, they must make difficult decisions on all the issues discussed above. They may conduct focus group interviews with representative samples of consumers from various market segments. They pre-test advertising materials on these groups to establish whether they have understood and effectively captured consumer attitudes and preferences before embarking on an expensive media campaign. As the campaign progresses, advertisers closely monitor the campaign's impact on product sales and also test consumer reaction in follow-up surveys. Mid-course corrections are often required, despite careful advance preparation. Lessons are constantly learned through this kind of monitoring and evaluation.

Public-sector efforts to change food behaviour rarely undertake this kind of market research, partly because of a lack of funds and relevant skills, but also in some cases because of a perception that such research is "purely academic" and of no practical benefit. Yet good market research can achieve cost savings and greater programme impact, issues of concern to programme managers.

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