Around the world, there are 2 billion people suffering from a potentially devastating form of malnutrition. But they might not even feel hungry. Micronutrient deficiency, sometimes referred to as “hidden hunger,” affects people who don’t get enough of the crucial vitamins and minerals that we can only get through our diet, including vitamin A, iodine, zinc, calcium and folate. Diets lacking in those and other essential micronutrients can lead to delayed cognitive development, weakened immunity, birth defects and death – even in people who get enough to eat.
Much of the health community agrees that a diverse and nutrient-rich diet is key to fighting micronutrient deficiency. But in parts of the world struggling with food insecurity, diversity often takes a backseat to quantity and convenience. So if people can’t access foods containing the necessary micronutrients, experts say, adding vitamins and minerals to the foods they already eat could be the next best thing. “Fortification is a very good technology to address poor quality diet for those who can’t afford it,” says Katharine Kreis, director of strategic initiatives at PATH.
According to UNICEF, micronutrient deficiency leads to stunted growth, cognitive delays and weakened immunity in millions of children. There are major health consequences for adults, too, including reduced productivity and greater susceptibility to disease. And pregnant women face increased risk for low birth weight, birth defects, stillbirth and even death.
“Iron deficiency affects more people than any other condition, constituting a public health condition of epidemic proportions,” the World Health Organization (WHO) reports. Pregnant women in developing countries are particularly vulnerable: Every second one is estimated to be anemic, while anemia contributes to 20 percent of all maternal deaths. “Women and girls have been largely forgotten in nutrition’s big picture,” says Agnes Guyon, senior technical advisor on nutrition at John Snow, Inc. (JSI).
Iron deficiency is the most common and widespread nutritional disorder, but there are other micronutrients that are severely lacking in the diets of millions of people. Approximately one-third of children living in the developing world suffer from vitamin A deficiency, particularly in sub-Saharan Africa and South Asia. According to the WHO, an estimated 250,000–500,000 vitamin A-deficient children become blind every year, half of them dying within 12 months of losing their sight.
Iodine is required by a fetus for brain and cognitive development. Every year, 18 million babies are born mentally impaired because their mothers have iodine deficiency and 38 million are born at risk of iodine deficiency; in total, 2 billion people are believed to have insufficient iodine intake.
Various nutrition programs focus on trying to diversify the range of foods available to people in the developing world, and educating parents on the need for nutrient-rich foods for themselves and their children. But they face challenges. “Barriers to good nutrition include approaches to food security that focus on cereals and starches rather than on availability in the market of diversified foods,” says Guyon.
To overcome those barriers, organizations such as UNICEF, the WHO and the Global Alliance for Improved Nutrition (GAIN) are looking to fortification. Mass fortification is the process of adding micronutrients to foods or condiments consumed regularly by the population, such as flour, sugar, salt and cooking oils. According to UNICEF, “Fortification programs are extremely effective in preventing micronutrient deficiencies at minimal cost – often only a few cents per person per year.”
Iodized salt is the fortification success story of the century. Some 71 percent of the world’s households now have access to iodized salt. In the past decade, the number of countries where iodine deficiency poses a public health problem has gone down by half. “We are now in an unprecedented position: on the verge of being able to eliminate iodine deficiency at a population level, in a sustainable way,” says Greg Garrett, director of food fortification at GAIN. “According to WHO, eliminating iodine deficiency would rank alongside some of the world’s biggest public health achievements like eradicating smallpox.”
Efforts at salt iodization are almost a century old, but fortifying other staples has become an important strategy for addressing micronutrient deficiency in the medium term. In Senegal, for example, where more than 60 percent of women of reproductive age are considered at high risk of inadequate micronutrient intake, GAIN has been giving financial and technical assistance to a local partner to fortify wheat flour with iron and folic acid and vegetable oil with vitamin A.
According to Garrett, in 2011 when GAIN started to scale up its fortification support in Senegal, most women did not consume fortified food products. By 2014, “over 70–80 percent were consuming fortified flour and oil at least once a week,” he says.
While fortifying staple foods is an extremely cost-effective solution, quality control can be an issue. “On average, fortified foods meet standards only 50 percent of the time,” says Garrett. The problems range from inadvertent shortcomings in the fortifying process to producers taking advantage of loopholes in the law to compliance. Solving those quality issues, Garrett says, is at the heart of GAIN’s work as the organization tries to facilitate cooperation between the public and private sectors.
Fortification and supplementation – providing specific micronutrients to people who need them, like iron and folic acid for pregnant women – together have great potential to help tackle hidden hunger, experts say. But, says Kreis at PATH, they are only “partial solutions.” The causes of micronutrient deficiency have underlying factors in poverty, disease and poor sanitation, as well as social and gender inequity issues that impede access to healthy food.
Stopping hidden hunger means ultimately addressing these structural issues. “Women’s empowerment is key to access to income and food,” says Guyon at JSI.