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ISSN: 2155-9600
Journal of Nutrition & Food Sciences

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The Role of Fortification and Supplementation in Mitigating the Hidden Hunger

Abeshu MA1* and Geleta B2

1John Snow, Inc (JSI)-Ethiopia, Addis Ababa, Ethiopia.

2Ethiopian Public Health Institute, Addis Ababa, Ethiopia.

*Corresponding Author:
Abeshu MA
Vaccine Supply Chain Advisor
John Snow, Inc (JSI)-Ethiopia
P.O Box 27236, Addis Ababa, Ethiopia
Tel: +251921462246
E-mail: [email protected]

Received date: December 18, 2015 Accepted date: January 19, 2016 Published date: January 27, 2016

Citation: Abeshu MA, Geleta B (2016) The Role of fortification and supplementation in mitigating the ‘hidden hunger’. J Nutr Sci 6:459. doi: 10.4172/2155-9600.1000459

Copyright: © 2016 Abeshu MA, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Micronutrients are nutrients required by the body in small amounts for normal physiologic functions. Despite the minuscule demand for micronutrients by the body, their deficiency results in a number of health complications. Globally, more than 2 billion people are affected by micronutrient deficiency where developing world takes most of the burdens. To make things worse, micronutrient deficiency often goes unnoticed for a long time in individuals before symptoms become apparent. Large scale interventions through fortification of foods and supplementation of micronutrients to circumvent the devastating consequences of micronutrient deficiencies are showing a great progress by reducing the number of morbidity and mortality attributed to them. At international scale, fortification of salt with iodine, iron and vitamin A supplementation to the most risky and vulnerable groups is considered the most successful micronutrient interventions to date.


Micronutrients; Fortification; Supplementation; Hidden hunger


Micronutrients are non-energy yielding class of nutrients such as vitamins and minerals that are needed, and therefore consumed, in small amounts, milligrams or micrograms daily, for ensuring optimal health and well-being. Since they are not synthesized by the body at all or in adequate amounts, they should be provided through diet [1]. Micronutrients have enormous health significance. It takes part in a variety of biological functions such as regulating enzyme and hormone actions, gene expression, cellular proliferation and differentiation, growth and development, and immune modulation. They are essential for the metabolism and utilization of the macronutrients [2].

Micronutrient deficiency, often, goes unnoticed within a community in spite of their insidious effects on immune system functioning, growth and cognitive development. It is for these reasons that micronutrient deficiencies have been referred to as “hidden hunger”. In individuals following popular diet plans, as suggested with food alone, there is high likelihood of becoming micronutrient deficient; a state shown to be scientifically linked to an increased risk for many dangerous and debilitating health conditions and diseases [3].

Micronutrients can be categorized as either Type 1 or Type 2. Type 1 micronutrients are those nutrients that, when not consumed in adequate amounts, result in specific deficiency diseases, and do not always affect growth. Rather, they affect the metabolism and immune competence before signs are apparent. These include deficiency of vitamin A, B1, B2, B3, B6, B12, C, D and folic acid, and minerals such as iron, calcium, copper, iodine, and selenium. In contrast, deficiency of type 2 micronutrients does not show specific clinical signs, but affects metabolic processes and result in growth failure, wasting, increased risk of edema, and lowered immune response that is attributed to the deficiency of specific minerals such as S, K, Na, Mg, Zn, P, and N deficiencies [4,5].

Therefore, this review highlights the magnitude and consequence of the major micronutrient deficiencies, discusses the role of fortification and supplementation in mitigating micronutrient deficiency, and offers some conclusions and recommendations.

Micronutrient Deficiency

Micronutrient deficiency is a serious public health concern throughout the world [6,7]. It is silent epidemics of vitamin and mineral deficiencies affecting people of all genders and ages. Literatures suggest that over 2 billion people are at risk for vitamin A, iodine, and/or iron deficiency globally [8-10]. In the developing world, 20% of the population suffer from iodine deficiency, 25% of children have subclinical vitamin A deficiency, and more than 40% of women are anaemic [11,12], increasing the risk of death, morbidity and susceptibility to infection, blindness, adverse birth outcomes, stunting, decreased cognitive capacity and mental retardation [4,13]. Micronutrient deficiencies are typically due to inadequate food intake, poor dietary quality, poor bioavailability attributed to the presence of inhibitors, mode of preparation, and interactions, and/or the presence of infections [8].

Micronutrient Estimated impact and efforts to address
Iodine Associated with brain damage. Easily mitrgated with iodized salt While incidence has declined dramatically in recent years due to the unroersal adoption of salt rodizahon starting in 1993. WHO estimates that 54 countnes still have some odme deticiency.
Vitamin A Associated with bhndness and mcreased rich Of disease and death tar small cliadren and pregnant women. Can be addressed through supplements, wtrclr axe now estimated to reach chridren at least once a year in 40 countnes. The UN Standing COntmrflee on NatntOn (UN/SCN) estimates that 140 milliOn children and? mrlhon pregnant women are VA dehcerit. pnnrarrly in Africa and South/Southeast Asia.In 1998. WHO. UNICEF. Canadian International Development Agency. USAID,and the Micoonutnent Initialise launched the VA Global tnrtative. This provides support to countnes in delrvenng VA supplements.
iron Associated with maternal death, impaired physical and cognitive development, increased nsk 01 rnnxbiddy in children, and reduced worti productisrty in adults. Can be addressed through tortihcat,on of wtreat products. WHO eslenates 2 billiOn people are anemic, and this is frequently exacerbated by infectious diseases. Malana, HIVI AIDS, hookworm intestatOn, schistosonriasis, and tuberculosis contribute to a high prevalence of anemia in some areas. Efforts to increase iron intake must be accompanied by efforts to control inleclious disease
Zinc Associated with reduced immnne stales in neonates and children. Prelirnmaiy research shows thaI addilional zinc can reduce incidence ol diarrhea end pneixnon/a m chrldren and improves maternal health. One estimate shows zinc as close to iron dehciency m contribution to Ihe global burden of disease. Can be provided through supplements.
Fiat ate Deficiency associated with increased risk of maternal death and complications in beth; also associated vath neural tube delects ix intents and with an estimated 200,000 severe birth defects every year. Can be addressed through tortilication wheat products.

Table 1: Micronutrient deficiencies and their estimated impacts [14].

Approaches to Mitigate Micronutrient Deficiency

The widespread recognition of the importance of micronutrient deficiencies in global health, and the potential to address such deficiencies relatively cheaply through fortification or supplementation has led to several multilateral efforts to support traditional interventions [7,14,15]. Supplementation and fortification are intervention strategies that often are aimed at the immediate or shortterm amelioration of the situation and often address the symptoms of micronutrient deficiencies [16].


Supplementation refers to the provision of added nutrients in pharmaceutical form (such as capsules, tablets, or syrups) rather than in food where it is most appropriate for targeted populations with a high risk of deficiency or under special circumstances, such as during pregnancy or in an acute food shortage [17,18]. Globally, supplementation with iron tablets is the most widely used strategy for the prevention and control of iron-deficiency or anemia in pregnancy. Pregnant women require nearly three times as much iron as nonpregnant women owing to the physiological demands of pregnancy (expanded red-blood-cell volume, the needs of the fetus and placenta, and blood loss at delivery).

Problem Presentation Intervention
Vitamin A deficiency Striking: blindness, increased child and maternal mortality risk Easy in children: infrequent high dose capsules
Iodine deficiency Striking: cretinism, dwarfism, goiter Easy: iodized salt
Iron deficiency Subtle: anemia, reduced cognitive development Difficult: e.g., frequent supplementation
General malnutrition-growth failure Subtle: smaller children Difficult: community -based programs
General malnutrition-starvation in emergencies Striking: emaciated and dying children and adults Easy (in principle): emergency food aid and other assistance

Table 2: Perceptions and relative priorities of interventions [11].

This high requirement is unattainable by most pregnant women in developing countries and therefore, iron supplementation is recommended during pregnancy on daily or weekly basis [18]. Iron supplementation is also found to effectively treat severe and moderate anemia in pre-school children [19].

Periodic distribution of high-dose vitamin A supplements, either universally to all preschool children or to targeted high-risk groups, is another most widely practiced intervention for the prevention and treatment of vitamin A deficiency throughout the world [18]. Given every 4-6 months, vitamin A is stored in the liver and mobilized, as needed; to meet the demands of target tissues [15,20] averts vitamin A deficiency disorders [21]. Similarly, in cases where iodine deficiency disorders are prevalent, iodized oil capsules are commonly used to fulfill daily iodine requirements of the body if iodized salt is unavailable [22].

Supplementation programmes are used as a short-term intervention measures. It has advantages of rapid coverage of a high-risk population by providing direct a controlled and concentrated dose of the micronutrient to the target group. In addition, supplementation has an immediate impact on micronutrient status and associated functional outcome. Most supplementation programs have been shown to be cost-effective in achieving their nutritional goals and health impacts. However, inadequate coverage (where deficient individuals are missed or reached irregularly), inability to sustain high coverage over long periods of time as financial, political, or other health priorities change, and poor compliance by target individuals (e.g., iron supplementation during pregnancy) hamper the long term goals. As a result, supplementation is mostly replaced with long-term, sustainable foodbased measures such as fortification and dietary modification, usually by increasing food diversity [15].


Food fortification stands out among public health interventions as one of the most effective methods of preventing nutritional deficiencies where it has contributed significantly to the virtual elimination of goiter, rickets, beriberi and pellagra in the Western world [23]. Fortification refers to the addition of nutrients to foods from which they were either absent or present in small amounts to increase the intake of one or more nutrients. It also includes additions to fulfill the role of another food in the diet [17]. Fortification can be done in three ways. First, by restoring the nutrients lost during food processing to their natural level (for example restoring B-vitamins which are lost during milling). Second, by increasing the level of a nutrient above that normally found in the food (for example adding extra iron to wheat flour or extra calcium to milk). Third, by adding nutrients that are not normally present in a food item otherwise considered a good vehicle for delivering micronutrients to the consumer (for example putting vitamin A into sugar, or iodine into salt) [12,17].

Fortification strategies utilize widely accessible, commonly consumed foods as a vehicle. The most widespread effort to date has been fortification of salt with iodine [23,24]. However, many other foods may be used as vehicles for a variety of micronutrients. Some of the common combinations are wheat products (cereal, bread or pasta) with one or more nutrients including calcium, iron, niacin, riboflavin, thiamine and zinc [25]. Milk can be fortified with vitamin D; fruit and fruit juices have been fortified with calcium and vitamin C. Fish sauce and soy sauce are also recognized as good vehicles [15,24,26].

Successful employment of fortification strategies requires centralized processing facilities, mechanisms for quality control, and social marketing and public education strategies [17]. The required infrastructure is often weak or lacking in developing countries, which reduces the potential for the success of fortification measures [27].


Figure 1: Types micronutrient fortification of food [23].

Adequate income and marketing channels are essential for such strategies to succeed, but the poor and nutritionally vulnerable are frequently less able to purchase fortified food products. Moreover, infrastructures; including roads and transportation systems are weak in many developing countries, where the majority of the populations are at high risk [17,28,29].

Food Vehicle Fortifying agent
Salt Iodine. iron
Wheat and corn flours, bread. pasta, rice Vitamin B complex, iron, folic acid, vitamin B12
Milk, margarine. yoghurts, soft cheeses Vitamins A and D
Sugar, monosodium glutamate, tea Vitamin A
Infant formulas, cookies Iron Vitamins BI and 1:32, niacin. vitamin K. folic acid, zinc
Vegetable mixtures amino acids, proteins Vitamins and minerals
Soy milk, orange juice Calcium
Juices and substitute drinks Vitamin C
Ready-to-eat breakfast cereals Vitamins and minerals
Diet beverages Vitamins and minerals
Enteral and parenteral solutions Vitamins and minerals

Table 3: Widely used fortified foods [9].

Conclusion and Recommendation

Fortification and micronutrient supplementation for the most vulnerable is proven to avert much of the morbidity and mortality associated to micronutrient malnutrition. Micronutrient deficiency often goes unnoticed within the societies which are otherwise healthy. Thus, individuals should be cautious about their daily food intakes. If developing countries like Ethiopia, where the prevalence of malnutrition related mortality accounts for almost half of the total under five age children, large scale micronutrient intervention through supplementation and fortification can be an option in the fight against malnutrition. However, chronic, high dose consumption of fortified foods and food supplements, often, is associated with over consumption and risk of toxicity. Therefore preliminary nutritional status of the intervention groups should be assessed. In addition, efficacy and safety of nutrients for supplementation should be addressed to avoid the consumption of counterfeited products. The causes of malnutrition are often multifactorial. Lasting fight against micronutrient deficiency requires understanding the dynamics of factors contributing to malnutrition. Thus, further studies regarding the status of micronutrients and the full picture of the effect of fortification and supplementation is recommended.


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