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The Economics of Food Fortification
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This paper summarizes some of the literature on the cost effectiveness and cost benefit of food fortification with selected micronutrients most relevant for developing countries. Micronutrients covered include iron, iodine, vitamin A, and zinc. The main focus is on commercial fortification, although home fortification and biofortification are mentioned. Fortification with iron, vitamin A, and zinc averts significant numbers of infant and child deaths and is a very attractive preventive health-care intervention. Fortification with iron, iodine, and potentially zinc provides significant economic benefits and the low unit cost of food fortification ensures large benefit:cost ratios, with effects via cognition being very important for iron and iodine. Fortification will not reach all individuals and is most attractive as an investment where there is a convenient food vehicle, where processing is more centralized, and where either the deficiency is widespread or the adverse effects are very costly even though only a small group is affected.
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“Food fortification is widely recognized as an effective strategy to reduce micronutrient deficiencies and improve public health (Horton, 2006;Prajapati P., 2024).”
From Cassava (Manihot Esculenta) Chips Fortified with Sagip Nutri Powder (2026) · cites this paper as Horton, 2006
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“, 2007), more sustainable than nutrient supplementation (Bouis, 1999), and a viable complementary strategy to food fortification, which relies on central processing of food and therefore may be less accessible, particularly to the rural poor (Bouis, 1999; Horton, 2006; Johns and Eyzaguirre, 2007).”
BackgroundRegulatory Monitoring of Fortified Foods: Identifying Barriers and Good Practices
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“This study confirms earlier analyses of the economic benefits of salt iodization by the WHO (39,40) and the Copenhagen Consensus (41), which have estimated a benefit–cost ratio of the order of 30:1, although others have suggested that the benefit–cost ratio may be as high as 70:1 (42).”
ResultCopenhagen Consensus 2008 Challenge Paper Hunger and Malnutrition
Horton, S., Alderman, H., & Rivera, J. Á. (2008) · Cited by 92
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“Iodine was omitted from the analysis because iodine content in foods depends heavily on local soil conditions, and salt iodization is an effective and cost-effective strategy to ensure adequate iodine intake.(21) More details on the nutrient gap assessment methods and findings are available elsewhere.”
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Gunnarsdóttir, I., & Dahl, L. (2012) · Food & Nutrition Research · doi:10.3402/fnr.v56i0.19731 · Cited by 75
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“Biofortification is believed to be cost-effective [11], more sustainable than nutrient supplementation [8], and a viable complementary strategy to food fortification, which relies on the central processing of food and whose products, therefore, may be less accessible, particularly to the rural poor [8, 12].”
BackgroundDrewnowski, A., Monterrosa, E. C., de Pee, S., Frongillo, E. A., & Vandevijvere, S. (2020) · Food and Nutrition Bulletin · doi:10.1177/0379572120945904 · Cited by 70
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Hoddinott, J. F. (2018) · Annals of the New York Academy of Sciences · doi:10.1111/nyas.13527 · Cited by 59
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Cimmino, F., Catapano, A., Petrella, L., Villano, I., Tudisco, R., & Cavaliere, G. (2023) · Frontiers in Bioscience-Landmark · doi:10.31083/j.fbl2802041 · Cited by 59
“Food fortifications are a cost-effective strategy for improving the population nutritional state [182] and were associated with strong economic advantages [183].”
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“The effectiveness of any fortification programme depends on a number of programme design choices, for example, the food chosen needs to be consumed by the targeted population, and the price increase of the final product should be kept low, so that no access barriers based on income are not created [53, 59].”
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“This strategy is especially practical if the deficiency is widespread across a population, which is the case with vitamin D in Germany((37)).”
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Zimmermann, M. B. (2022) · Proceedings of The Nutrition Society · doi:10.1017/s0029665122002762 · Cited by 44
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“Fortification plays an important role in providing lowcost nutrients [38].”
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A child-sensitive approach to social protection: serving practical and strategic needs
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“Investments in micro-nutrients and food fortification are also found to have high returns, especially for children (Horton, 2006, 2008).”
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“To date salt iodization, flour fortification with folic acid, and sugar/oil fortification with vitamin A are amongst the most cost-effective fortification strategies (8, 10, 11).”
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“Thus, for many people, the potential use of insects to treat malnutrition could be a cheap solution that is in line with existing food habits and preferences (Horton 2006; Moreira-Ara ujo et al. 2008).”
BackgroundWhich Choice of Delivery Model(s) Works Best to Deliver Fortified Foods?
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“Fortification is overall more cost-effective than supplementation [76].”
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Knez, M., & Stangoulis, J. (2021) · Nutrition Research Reviews · doi:10.1017/s0954422421000342 · Cited by 36
Cormick, G., Betrán, A. P., Metz, F., Palacios, C. S., Beltran‐Velázquez, F., Garcia‐Casal, M. N., Peña‐Rosas, J. P., Hofmeyr, G. J., & Belizán, J. M. (2020) · Nutrients · doi:10.3390/nu12041022 · Cited by 36
“Food fortification has been shown to be an economical way to increase calcium intake, especially if the deficiency is widespread, the target population is hard to reach, and if the technological capacity and distribution networks already exist in the country [27,67].”
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“Both fortification and biofortification can be cost-effective strategies to address micronutrient intakes (179, 180), and dietary diversity is typically considered an ideal long-term solution to nutritional well-being.”
BackgroundBóo, F. L., Palloni, G. E., & Urzúa, S. (2014) · Annals of the New York Academy of Sciences · doi:10.1111/nyas.12368 · Cited by 34
“Variables (1) (2) (3) (4) (5) (6) (7) (8)”
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Managing the Vitamin A Program Portfolio: A Case Study of Zambia, 2013–2042
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Value creation and sorghum-based products: what synergetic actions are needed?
Deribe, Y., & Kassa, E. (2020) · Cogent Food & Agriculture · doi:10.1080/23311932.2020.1722352 · Cited by 33
“A different paradigm in the enhancement of food quality is introducing the micronutrient density into staple crops through the techniques of genetic modification or biofortification (Horton, 2006).”
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Thakur, S., Singh, A. P., Insa, B., & Sharma, S. (2023) · Sustainable Food Technology · doi:10.1039/d3fb00079f · Cited by 32
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“Fortification involves enriching foods with essential micronutrients (such as salt with iodine) and is most cost effective with centralized production of commercial products (Horton 2006), while supplementation, usually in the form of capsules (e.”
Rahman, M. M., Erskine, W., Materne, M., MCMURRAY, L. M., Thavarajah, P., Thavarajah, D., & Siddique, K. H. M. (2014) · The Journal of Agricultural Science · doi:10.1017/s0021859614000495 · Cited by 31
“Fortification of wheat flour with Fe costs US$0.12/person/year (Layrisse et al. 1996) and with Zn costs US$0.06–0·24/person/year (Horton 2006).”
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“Of the interventions, food fortification holds promise, because it does not require changes in dietary patterns, is cost-effective, and can reach large portions of the population without costly government distribution schemes; it is potentially sustainable provided demand is sufficient (1,2).”
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Friesen, V. M., Mbuya, M. N. N., Aaron, G. J., Pachón, H., Adegoke, O. J., Noor, R. A., Swart, R., Kaaya, A. N., Wieringa, F. T., & Neufeld, L. M. (2020) · Journal of Nutrition · doi:10.1093/jn/nxaa167 · Cited by 28
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“In countries affected by IDD, it is considered that iodine must be added routinely to complementary foods in order to increase iodine content derived from daily intake [44-48].”
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“Food fortification has proven to be a sustainable, cost-effective strategy to improve vitamin and mineral status [17, 18], with documented evidence for the efficacy and effectiveness of vitamin A fortification initiatives [19–24].”
BackgroundFood Aid Modality Selection Problem
Sahinyazan, F. G., Rancourt, M., & Verter, V. (2020) · Production and Operations Management · doi:10.1111/poms.13287 · Cited by 25
“Then s hrk is modeled as a binary variable, because nutrient intake levels ( Θ k ) used in the model are the bare minimums to prevent metabolic problems, and nutritional economists define two states: deficient and non-deficient (Horton 2006).”
MethodIron-Enriched Nutritional Supplements for the 2030 Pharmacy Shelves
Verna, G., Sila, A., Liso, M., Mastronardi, M., Chieppa, M., Cena, H., & Campiglia, P. (2021) · Nutrients · doi:10.3390/nu13020378 · Cited by 25
Making Agriculture Pro-Nutrition: Opportunities in TanzaniaPreprint
Ecker, O., Mabiso, A., Kennedy, A. S., & Diao, X. (2011) · RePEc: Research Papers in Economics · Cited by 24
Nishanth, S., Prasanna, R., Hossain, F., Muthusamy, V., Shivay, Y. S., & Nain, L. (2021) · Rhizosphere · doi:10.1016/j.rhisph.2021.100421 · Cited by 23
Bird, J. K., Barron, R., Pigat, S., & Bruins, M. J. (2022) · Journal of Nutritional Science · doi:10.1017/jns.2022.47 · Cited by 22
“Mandatory fortification provides another low-cost means to increase specific nutrients that are challenging to obtain from the diet alone((39)).”
BackgroundRole of Iron in Alleviating Heavy Metal Stress
Hassan, Z. U., Ali, S., Rizwan, M., Ali, Q., Haider, M. Z., Adrees, M., & Hussain, A. (2017) · Springer eBooks · doi:10.1007/978-3-319-58841-4_13 · Cited by 21
Addressing the Fortification Quality Gap: A Proposed Way Forward
Rowe, L. A. (2020) · Nutrients · doi:10.3390/nu12123899 · Cited by 21
Davidsson, L., Sarker, S. A., Jamil, K. A., Sultana, S., & Hurrell, R. F. (2009) · American Journal of Clinical Nutrition · doi:10.3945/ajcn.2008.27353 · Cited by 19
The Policy of Compulsory Large-Scale Food Fortification in Sub-Saharan Africa
Bell, V., Rodrigues, A. R., Ferrão, J., Varzakas, T. H., & Fernandes, T. H. (2024) · Foods · doi:10.3390/foods13152438 · Cited by 23
Tackling Hidden Hunger: Understanding Micronutrient Deficiency and Effective Mitigation Strategies
Kumar, A., Kerketta, A., Dewali, S., Sharma, N., Panda, A. K., & Bisht, S. S. (2023) · Springer eBooks · doi:10.1007/978-3-031-40908-0_12 · Cited by 18
Bruins, M. J., Kupka, R., Zimmermann, M. B., Lietz, G., Engle‐Stone, R., & Kraemer, K. (2016) · Maternal and Child Nutrition · doi:10.1111/mcn.12334 · Cited by 17
“Economic analyses suggest that fortification and/or targeted supplementation with, for instance, iron, zinc, vitamin A, folic acid and iodine can be highly cost-effective (Horton 2006; Horton et al. 2008; Edejer et al. 2005; Yi et al. 2011).”
BackgroundInfluentialSedlander, E., Rimal, R. N., Talegawkar, S. A., Yilma, H., & Munar, W. A. (2018) · Gates Open Research · doi:10.12688/gatesopenres.12808.2 · Cited by 18
Vitamin Bullets. Microencapsulated Feeds to Fortify Shellfish and Tackle Human Nutrient Deficiencies
Willer, D. F., & Aldridge, D. C. (2020) · Frontiers in Nutrition · doi:10.3389/fnut.2020.00102 · Cited by 18
“Costs are comparable or lower than providing a supplemental pill, and compliance is easier; poor consumers will continue to buy their now marginally more expensive food whereas they are unlikely to make an additional purchase to buy supplements (2, 5, 14).”
BackgroundDasgupta, S., Mustafa, G., Paul, T., & Wheeler, D. R. (2020) · World Development · doi:10.1016/j.worlddev.2020.105201 · Cited by 18
Singh, B., Goutam, U. K., Kukreja, S., Siddappa, S., Sood, S., Sharma, J., & Bhardwaj, V. (2021) · Potato Research · doi:10.1007/s11540-021-09508-x · Cited by 17
Finkelstein, J. L., Herman, H. S., Guetterman, H. M., Peña‐Rosas, J. P., & Mehta, S. (2018) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd013227 · Cited by 19
Pyo, E., Tsang, B. L., & Parker, M. (2021) · Nutrition Reviews · doi:10.1093/nutrit/nuab107 · Cited by 15
Mark, H. E., Assiene, J. G., Luo, H., Nankap, M., Ndjebayi, A. O., Ngnie‐Teta, I., Tarini, A., Pattar, A., Killilea, D. W., Brown, K. H., et al. (2019) · Current Developments in Nutrition · doi:10.1093/cdn/nzz076 · Cited by 15
Are, A. K., Srivastava, R. K., Govindaraj, M., Gorthy, S., Gaddameedi, A., Kunapareddy, A., Kotla, A., & Jaganathan, J. (2018) · Elsevier eBooks · doi:10.1016/b978-0-12-811527-5.00003-4 · Cited by 14
Cost‐effectiveness of sunflower oil fortification with vitamin A in Tanzania by scale
Walters, D., Ndau, E., Saleh, N., Mosha, T. C. E., & Horton, S. (2019) · Maternal and Child Nutrition · doi:10.1111/mcn.12720 · Cited by 14
“The estimates of this study, however, show that fortification may not always be as cost‐effective as the previously reported estimates of $18 per DALY averted in Uganda and $35 per DALY averted in the Southern and Eastern Africa region (Fiedler & Afidra, 2010; Horton, 2006).”
ResultSelf-citationTimotijević, L., Timmer, A., & Ogunlade, A. O. (2013) · Springer eBooks · doi:10.1007/978-1-4614-7110-3_18 · Cited by 14
Ekoe, T., Bianpambe, O. I., Nguefack, F., Pondi, D. M., Sop, M. M. K., Hays, N. P., Medoua, G. N., & Koki, P. N. (2020) · Food Science & Nutrition · doi:10.1002/fsn3.1639 · Cited by 16
“The World Health Organization (WHO) has reported that iron fortification of foods is the best preventive measure of iron deficiency from a cost-effectiveness point of view (Baltussen, Knai, & Sharan, 2004; Horton, 2006).”
BackgroundSedlander, E., Rimal, R. N., Talegawkar, S. A., Yilma, H., & Munar, W. A. (2018) · Gates Open Research · doi:10.12688/gatesopenres.12808.1 · Cited by 13
Assessing Alternative Industrial Fortification Portfolios: A Bangladesh Case Study
Fiedler, J. L., Lividini, K., Guyondet, C., & Bermúdez, O. I. (2015) · Food and Nutrition Bulletin · doi:10.1177/156482651503600106 · Cited by 13
Scappaticci, G., Mercanti, N., Pieracci, Y., Ferrari, C., Mangia, R., Marianelli, A., Macaluso, M., & Zinnai, A. (2024) · Foods · doi:10.3390/foods13060825 · Cited by 12
“Food fortification stands out as one of the most sustainable and cost-effective approaches to improving public health [5–7].”
BackgroundReducing dietary salt intake and preventing iodine deficiency: towards a common public health agenda
Webster, J. L., Land, M., Christoforou, A., Eastman, C. J., Zimmermann, M. B., Campbell, N. R. C., & Neal, B. C. (2014) · The Medical Journal of Australia · doi:10.5694/mja14.00818 · Cited by 12
Review of the Micronutrient Situation in Rwanda
Arsenault, J., & Olney, D. (2021) · Food and Nutrition Bulletin · doi:10.1177/0379572120975298 · Cited by 9
“Food fortification is one of the most cost-effective strategies to address micronutrient deficiencies.(39) An advantage of fortification is that it can reach the entire population without requiring consumers to change dietary behaviors.”
Background
Metadata
- Authors
- Horton, S.
- Affiliations
- Wilfrid Laurier University (CA)
- Corresponding author
- Horton, Sue
- Venue
- The Journal of Nutrition
- Publisher
- Elsevier BV
- Published
- 2006-04
- Volume
- 136
- Issue
- 4
- Pages
- 1068-1071
- ISSN
- 0022-3166 (ISSN-L)
- OpenAlex
- W1946220486
- Cited by
- 197
- References
- 8
- Citations by year
- 2026: 3 · 2025: 8 · 2024: 6 · 2023: 15 · 2022: 7 · 2021: 15 · 2020: 21 · 2019: 10 · 2018: 15 · 2017: 8 · 2016: 7 · 2015: 9 · 2014: 13 · 2013: 12 · 2012: 10
- FWCI
- 6.46
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of Nutrition (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Nursing › Nutrition and Dietetics › Child Nutrition and Water Access
- Life Sciences › Agricultural and Biological Sciences › Food Science › Nutrition, Health, and Society Studies
- Health Sciences › Medicine › Hematology › Iron Metabolism and Disorders
- Keywords
- food fortification, cost-effectiveness, cost-benefit analysis, micronutrients, iron, iodine, vitamin A, zinc, infant and child mortality, home fortification, biofortification, cognitive effects, developing countries, public health investment
- MeSH terms
- Cost-Benefit Analysis, Developing Countries, Food, Fortified, Humans, Iodine, Iron, Vitamin A, Zinc, Micronutrients
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