A comprehensive new systematic review published in The Journal of Nutrition provides the latest evidence that large-scale food fortification is a highly cost-effective intervention for reducing global malnutrition.
The research team, made up of scientists from Cochrane Response, the Food Fortification Initiative, Emory University, and TechnoServe, examined 56 studies presenting over 200 economic analyses from 63 countries, including more than 40 low- and middle-income economies. They found that the vast majority of food fortification programs deliver substantial health benefits relative to costs.
Hidden hunger, a type of malnutrition that occurs when a person does not consume enough of the essential vitamins and minerals – micronutrients – they need to survive or thrive, impacts millions worldwide and leads to substantial mortality and morbidity. Children and pregnant women are particularly susceptible, with an estimated 56% of children aged 6-59 months and 69% of non-pregnant women aged 15-49 years suffering from hidden hunger globally. Hidden hunger can worsen during periods of food insecurity and rising food prices, as vulnerable populations struggle to access a varied, nutritious diet.
The systematic review, which represents the most comprehensive economic analysis of food fortification ever conducted, found strong and consistent evidence supporting large-scale food fortification as a cost-effective intervention. The study's key findings demonstrate that fortification programs are a great investment because the benefits far outweigh the costs.
Favorable cost-effectiveness
Among the 232 main cost-effectiveness analyses, 58% reported small incremental cost-effectiveness ratios (ICERs) of less than $150 per disability-adjusted life year (DALY) averted. Eighty-four percent had ICERs below $1,000 per DALY averted compared to no fortification (converted to US$ in 2022). ICER measures the incremental costs per incremental health effect. DALY is an established measure of disease burden calculated based on years of life lost and years lived with disability.
These findings demonstrate that fortification programs provide excellent value; they cost very little compared to the good they do.
All 47 benefit-cost ratios calculated in the included studies were positive, indicating that, in monetary terms, the benefits of fortification outweighed the associated costs. Additionally, six out of eight cost-utility analyses found fortification was both less expensive and more effective than no fortification.
The study covered a broad range of food and nutrient combinations. The addition of vitamin A, vitamin B9, iron, and iodine to staple foods, primarily cereal grain products (especially wheat flour) and condiments such as edible oils, sugar, and salt, were the most analyzed combinations.
"This research provides the most up-to-date data about the cost-effectiveness of food fortification on a global scale. The findings highlight the economic feasibility and tremendous potential of fortification programs to address micronutrient deficiencies and prevent their related deaths and illnesses. Large-scale food fortification stands out as a highly cost-effective public health intervention, and these results may provide useful indicators for evidence-informed decision making, especially in resource-constrained economies."
– Dr. Elise Cogo, lead author and epidemiologist at Cochrane Response
Fortification triumphs where budgets are tightest and health burdens are greatest
To further illustrate the cost-effectiveness of fortification, the review presented additional results using example economic thresholds based on gross domestic product (GDP) per capita calculated for each study country. These analyses (from ICERs) showed that overall, 87% of interventions fell within 50% of a country's GDP per capita, 84% of interventions in low- and middle-income countries were below 35% of GDP per capita, and 71% of interventions in low-income countries were less than 20% of GDP per capita: all indicators of cost-effective interventions in a wide variety of contexts.
"The decision by policymakers to enact or strengthen food fortification programs is influenced by many factors, including costs and cost-effectiveness. Fortification has been championed as a cost-effective nutrition strategy since the Copenhagen Consensus ranked it among the top cost-effective nutrition interventions to prioritize in 2008. Researchers have published many studies since 2008, and we wanted to better understand and interpret their findings. This comprehensive assessment provides a much-needed, updated case for increased investment in and expansion of food fortification initiatives worldwide. The evidence shows that fortification programs consistently deliver exceptional value for money while addressing some of the world's most pressing nutrition challenges."
– Becky Tsang, Senior Technical Advisor at the Food Fortification Initiative
Prioritizing cost-effective nutrition interventions
The study's findings come at a critical time when dramatic global aid cuts in 2025 have significantly affected the total amount available for health programs, with cuts equating to 44% of the $1.6 billion in aid provided in 2022 for malnutrition. These devastating reductions will increase the number of malnourished people, and it will put an estimated 2.3 million severely malnourished children at risk, potentially causing an estimated 369,000 preventable child deaths annually. The cuts jeopardize vital nutrition programs worldwide, leading to severe consequences in many low- and middle-income countries, and pose a significant setback to global efforts to combat malnutrition and its short- and long-term impacts. As such, prioritizing cost-effective nutrition interventions like fortification are more important than ever for governments.
The research team, funded by the United States Agency for International Development (USAID), brings expertise in epidemiology, economics, and nutrition. They noted that while the review highlighted limitations in the quality of reporting in existing studies, the overwhelming consistency of positive results across diverse contexts and methodologies provides confidence in the cost-effectiveness of large-scale food fortification programs.
This systematic review affirms the positive economic impact of food fortification and provides valuable insights for policymakers, global health advocates, and organizations working to combat hidden hunger worldwide. The findings strengthen the case for increased investment in food fortification as a proven, cost-effective strategy for improving global nutrition and health outcomes.
About Cochrane Response
Cochrane Response is the evidence consultancy team within the Cochrane Collaboration. The Cochrane Collaboration is regarded as the ‘gold standard’ source for trusted evidence synthesis globally, best known for publishing high-quality systematic reviews in the Cochrane Library. The Cochrane Response team provides customized, comprehensive evidence synthesis services and literature review services for policymakers, guideline developers, government agencies, and research groups across the globe. The team is made up of systematic reviewers with expertise in a wide range of evidence synthesis methods, applying Cochrane’s methodological rigor and high standards to a range of research questions.
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