INTERVIEW: In four years, 125.7m more Nigerians gained access to fortified food, says Gates Foundation

‘MAYOWA TIJANI, TheCable’s editor-at-large, speaks with Caroline Jehu-Appiah, deputy director, Health and Nutrition, at the Nigeria Country Office of the Gates Foundation, on the recently released National Food Consumption and Micronutrient Survey Report and issues around using food fortification to combat malnutrition, anaemia and other micronutrient deficiency illnesses.

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TheCable: Can you provide, an overview of the key findings from the recently published National Food Consumption and Micronutrient Survey Report in Nigeria?

Caroline Jehu-Appiah: This important survey marks a significant milestone towards understanding and improving the nutritional status of Nigerians and is the third nationally representative survey of its kind in Nigeria.

Micronutrient deficiencies, particularly vitamin and mineral deficiencies, are a significant public health concern in Nigeria, affecting millions of people, especially women and children. These deficiencies can lead to anaemia, impaired cognitive development, weakened immunity, and increased risk of morbidity and mortality.

From the preliminary findings, 1) there is a high level of food insecurity, and the proportion of food insecurity is reduced with higher education; 2) consumption of biofortified crops is low; (3) stunting and anaemia are public health problems and there are zonal differences. Specifically, 31 percent of children (aged 6-59 months) were found to be mildly anaemic, 29 percent were moderately anaemic, and 2 percent were severely anaemic. Anaemia was more prevalent in children in the Northwest zone (73 percent). Additionally, at the national level, about 55 percent of women of reproductive age suffered from anaemia. The prevalence of mild anaemia was 31 percent, moderate anaemia was 22 percent, and severe anaemia was 1 percent. Anaemia was highest in women of reproductive age in the Northeast zone (46 percent).

Food fortification is a proven strategy to address micronutrient deficiencies. By enriching staple foods with essential vitamins and minerals, we can improve the nutritional quality of our diet and prevent deficiencies. For instance, from 2020, we have seen that the supply of wheat flour fortified with iron and folic acid also increased by 68 percent accessible to 92 percent of the population, up from 54 percent.

In addition, the supply of cooking oil fortified with Vitamin A increased by 28 percent. From all of these, we have an additional 125.7 million more Nigerians with access to fortified sugar, 73.5 million more to fortified wheat flour and 13.8 million more to edible oil. This progress recorded within just 4 years is enough motivation to scale up the coordinated effort.

Nigeria has made significant progress in food fortification, and this survey will help us assess our progress, identify gaps, and inform evidence-based decision-making. The survey demonstrates the effectiveness of the standardized Micronutrient Fortification Index (MFI), a self-regulatory platform created to provide public ranking of companies and branded products with the aim of monitoring compliance, efficiency, effectiveness, and accountability in food fortification performance.

We currently have 31 brands representing 15 companies in the ranking index circle in Nigeria. The publicly listed brands now cover about 80% of the flour milling market, about 88% of the sugar market and 40% of the edible oil market, reaching approximately 134 million Nigerians. We are also witnessing growth in brands and expansion of private food processing companies that are complying with the national food fortification standards.

On the regulatory side, we have seen strong government participation and commitment at the highest level. The CEO Forum and Inter-Ministerial Roundtable are some of the platforms set up to continue to enrich the partnerships and engagement with the regulatory environment as well as the private sector. The report also reflects a generally positive outlook with regard to compliance by food producing and processing companies and the regulatory authorities.

TheCable: Has the foundation been monitoring the food fortification situation in Nigeria? If not, why? If yes, what is the most significant impact of food fortification over the past decade?

Caroline Jehu-Appiah: The Gates Foundation is collaborating with strategic partners from the private and public sectors to participate and monitor food fortification in Nigeria, and we are happy to report significant progress. So far, we have observed an improvement in the compliance to the 3 components of food fortification.

First, there is an increase in commercial and industrial fortification, where large-scale food processing and producing industries are applying fortification on corn meal, wheat flour, sugar and cooking oil. This increase is important given that this category of foods forms the basis of the Nigerian diet. We have also observed an increase in home fortification of Vitamin D drops. Bio-fortification is also on the evident increase as large-scale food producers are breeding crops higher in vitamins and minerals to increase nutritional value.

 As a result of investments in food fortification and other nutrition interventions, the situation today is much better than a decade ago, when insufficient consumption of iron, Vitamin A and iodine was prevalent among children and pregnant women, exposing them to high-risk dangerous health conditions, disease, and death.

TheCable: What are the main challenges faced in the implementation of Large-scale food fortification (LSFF) in Nigeria and how do stakeholders address them?

Caroline Jehu-Appiah: At the Gates Foundation, we understand the need to build sustainable systems within private and public sectors and working together with high-level partners in government and industry has helped to harmonize and strengthen the food fortification ecosystem in Nigeria.

The biggest challenge with any initiative is sustainability and acceptability amongst the people. Our program design from the onset anticipates worst-case scenarios. With regards to that, currently, the rate of integration of necessary life-saving micro-nutrients into staple food of an average Nigeria is on the right footing; whether you are rich or poor, as long as you can access common staple food as flour, oil and even beverage, you can be sure that to a large extent, the food is fortified with essential lifesaving nutrients.

In 2024, the Government of Nigeria released a report of a national food consumption and micronutrient status survey, which fills critical data gaps that had long plagued LSFF program design and monitoring. These data are critical to help inform which nutrients and food vehicles should be prioritized in order to have the greatest impact on the population’s public health. We are addressing this by supporting local decision-makers to leverage new secondary data sources and innovative modelling and machine learning techniques to gauge the distribution of micronutrient burden and coverage. We are also generating consensus around new metrics and data use to ensure that Large Scale Food Fortification reaches the most vulnerable, including the poor, women, and girls while a new Data Innovation Alliance will align diverse partners on vitamin and mineral deficiency proxy indicators and use new technologies to analyze existing primary and secondary data in new ways.

TheCable: Could you elaborate on the “Millers for Nutrition” initiative and its role in advancing food fortification in Nigeria?

Caroline Jehu-Appiah: Millers for Nutrition is an industry-led coalition that aims to address malnutrition by ensuring that Nigerians have access to the nutritious food they need to lead healthier and more productive lives. It was launched in March 2024 during the 9th Agrofood Nigeria Exhibition and Summit.

This initiative was launched in partnership with the Federal Government of Nigeria to ensure access to adequate nutrition. The data shows that undernutrition is responsible for one in five maternal deaths and nearly half of all deaths of children under five—and holds back millions more from leading healthy and productive lives.

You will agree with me that this is coming at a critical time in Nigeria as we are beginning to see progress in food fortification efforts across the country. Millers for Nutrition is being implemented in seven other countries across Africa and Asia including Bangladesh, Ethiopia, India, Indonesia, Kenya, Pakistan and Tanzania, and across three staple food vehicles: rice, edible oil and flour (wheat and maize). The coalition is working towards reaching one billion people by 2026 with fortified flour, rice and edible oil.

The initiative is open to millers in the country and those who join will receive free technical support to make food fortification easier and more accessible. The group usually shares practical tools that will help millers adopt food fortification best practices.

Key stakeholders have already welcomed the creation of the coalition and the drivers have assured that Millers for Nutrition will continue to enrich processed food with necessary vitamins and minerals. And not just that, consumers will see detailed fortification information on the products they purchase for consumption.

TheCable: What has been the role of critical partners like The Gates Foundation, TechnoServe, and GAIN in these fortification efforts?

Caroline Jehu-Appiah: Having been a media ally on this journey, you will agree that these partners and many more are working in a concerted effort to improve critical health outcomes through Large-Scale Food Fortification in Nigeria. We have committed resources and funding at varying scales. For example, the Gates Foundation has committed $10 million in grants into food fortification in Nigeria, Kenya, and Tanzania, in line with its fight against malnutrition in Africa. One of the primary investments in food fortification is a partnership with TechnoServe, a nonprofit consortium of world-class food companies, which is aimed at strengthening the ability of food processors to comply with fortification standards and support the fortification-enabling environment.

The stakeholders highlighted that one in three children in Nigeria are stunted, while two out of three are chronically malnourished, due to lack of essential micronutrients. The absence of essential nutrients diminishes productivity, reduces IQ points by 10-15 percent and cuts gross domestic product (GDP) by two to three percent. To help tackle this, we will support about 40 food companies in Nigeria to achieve the goal of standardized food fortification. The four-year initiative will help food companies in Nigeria, Kenya, Tanzania to improve competitiveness while increasing the availability of fortified foods.

The Nigerian chapter of the initiative for strengthening African processors of fortified food was launched in Lagos recently with major stakeholders in attendance and it is no doubt an important way that private-sector food producers can ensure that the food they produce contains the nutrients that consumers need.

TheCable: What specific health outcomes have been linked to large-scale food fortification in Nigeria, particularly concerning stunting rates?

Caroline Jehu-Appiah: To set the context; undernutrition contributes to 53 percent of under-five mortality in Nigeria. Many children die because of undernutrition and the inability to mount an effective response to infectious diseases, and we also know that good nutrition is essential for children’s physical and cognitive development.

We also know that there are many ways to tackle malnutrition; but one fundamental way is to ensure that the food that the people eat has essential vitamins and minerals –  vitamin A, iodine, folic acid, iron and zinc. Large-scale food fortification is a safe, proven and cost-effective way to deliver these micronutrients to the people who need them most.

It is important to note that in Nigeria, LSFF has been linked to several significant health outcomes, particularly in reducing micronutrient deficiencies. It also helps in addressing stunting, Neural Tube Defects (NTD) and anaemia.. Vitamin A deficiency, for example, is a major public health issue in Nigeria today, especially among children and pregnant women. We are optimistic that fortifying staple foods like cooking oil and wheat flour with vitamin A will continue to result in reducing this deficiency, resulting in healthier mothers and children.

The 2021 FMCS survey estimates that 31% of preschool kids have Vit A deficiency. That’s huge but there is more work to be done, which is why the partners are not slowing down. We cannot afford to slow down. LSFF has broadly improved the micronutrient status of the Nigerian population, particularly for vitamins and minerals such as vitamin A, iron, folic acid, and iodine. This is according to the 2021 evaluation by the International Food Policy Research Institute (IFPRI), which indicated that the fortification of edible oil and wheat flour reached over 80% of the Nigerian population, leading to substantial improvements in overall micronutrient intake and health status.

TheCable: In terms of awareness, is the public aware that it should demand fortified food products? What is  the plan to raise that knowledge base?

Caroline Jehu-Appiah: The level of public awareness regarding the value of food fortification in Nigeria is relatively low, though there are ongoing efforts to scale up. Despite the government’s policies and support from organizations such as the Global Alliance for Improved Nutrition (GAIN), TechnoServe, the Gates Foundation and other partners, there remains a significant gap in understanding among the general population about the benefits of fortified foods. Which is why we are committed to keeping the conversation going.

Partners are working assiduously to ramp up the dissemination of information on the benefits of food fortification to households. Unfortunately, the cause of this low awareness includes social norms and socio-economic challenges. A good example is how many people at the household level can recognize malnutrition but fail to associate it with the lack of fortified foods, sometimes they attribute it to spiritual problems instead.

Despite these challenges, we will not stop the efforts to continually raise awareness through educational campaigns targeting traditional institutions and religious leaders. As community gatekeepers, they play a crucial role in community dynamics, behaviour change and compliance. Additionally, enforcement agencies like the Standards Organization of Nigeria (SON) have been active in monitoring markets to ensure compliance with food fortification standards and have collaborated with international bodies to enhance public knowledge on the benefits of consuming fortified foods.

And this is where you come in. The media has a significant role to play in awareness building and demand creation. Part of the plan is to engage the media as critical thought partners in these campaigns.

TheCable: How does the National FCMS report align with global nutrition goals and the SDGs?

Caroline Jehu-Appiah: As I mentioned earlier, the National FCMS report fills critical data gaps that had long plagued LSFF program design and monitoring. These data are critical to help inform which nutrients and which food vehicles should be prioritized in order to have the greatest impact on population public health. It also demonstrates a comprehensive approach to tackling malnutrition, aligning with the global agenda to improve health, reduce hunger, and achieve sustainable development and effective Human Capital Development (HCD).

It seeks to improve health and reducing healthcare costs, fortified foods can help lift families out of poverty (SDG 1); Improve general health outcomes for all (SDG 3); Enhance nutrition particularly benefitting women and children, supporting maternal health and reducing gender disparities in health outcomes (SDG 5); Ensure productive human capital that can contribute more effectively to the economy (SDG 8); and help to bridge the nutritional gap between different socioeconomic groups, promoting equality (SDG 10).

TheCable: With all the progress made, what are the next steps to scaling up food fortification initiatives in Nigeria?

Caroline Jehu-Appiah: The need to scale and sustain is especially important. This is because good nutrition is at the heart of economic and social development and is key to reducing inequality, eliminating poverty, and raising human capital. Micronutrient deficiencies are responsible for the preventable deaths of more than three million children worldwide each year.

At the Gates Foundation, we believe these deaths are preventable, which is why our key priority is to work across food, health and social protection systems to deliver both nutrition and care that people need to live healthy and productive lives.

The survey underscores the importance of folate deficiency, a major cause of neural tube defects and the potential reach of condiments, such as bouillon, which is consumed by the entire population, but in greater amounts among low-income households.

We will continue investing in large-scale food fortification as part of a multi-pronged nutrition strategy with a focus on new vehicles such as bouillon and rice. We will also continue to drive compliance through a multi-stakeholder initiative to digitize the fortification value chain, which will allow automatic tracking of fortification. We are working with technology and commercialization partners to design and evaluate digital minimum viable products (MVPs) in Bangladesh, India, and Nigeria.

We are paying particular attention to cultural fit and necessary change management components and are investing in improved compliance systems for optimal performance. Within five years, we aim to achieve locally sustained, cost-effective, digital quality assurance and quality control systems—driven by mills and supported by food authorities and regulatory bodies. Working with the government and all of its partners, our collective resolve is to ensure that mothers and children survive and thrive.