Nigeria faces a triple burden of malnutrition, consisting of undernutrition, micronutrient deficiencies, and overnutrition, which manifests as overweight and obesity – all of which are driven by conflicts, food and nutrition insecurity, and ineffective policy management, amongst other factors that contribute to worsening the country’s overall health outcomes.

According to the World Health Organisation (WHO), micronutrient deficiencies, particularly iron, folic acid, iodine, and vitamin A, are a public health concern in low and middle-income countries, including Nigeria, affecting millions of people, especially women and children.

Micronutrients perform a range of functions, including the production of enzymes, hormones, and other substances required for growth, good health, and development. When they are lacking, micronutrient deficiencies can lead to conditions such as anaemia – a blood disorder that occurs where there is a reduction in the number of circulating red blood cells, consequently limiting their ability to effectively transport oxygen needed for bodily functions.

Micronutrient deficiency can also result in reduced energy levels, impaired cognitive development, and weakened immunity, ultimately leading to reduced educational outcomes, diminished work productivity, and increased risk of disease and mortality.

Tackling the scourge of micronutrient deficiency and its attendant health problems can be managed by consuming safe, diverse, and nutritionally balanced diets. On a country-wide scale, combating micronutrient malnutrition requires concerted and targeted efforts from governments to enhance the nutritional quality of the national food supply. This often involves strategies such as agriculture-sensitive nutrition programmes, food fortification, among other measures, to ensure a healthier population.

Food fortification is an evidence-informed public health intervention endorsed by public health professionals, governments, and the WHO to prevent or control micronutrient deficiencies among populations. It involves the addition of one or more micronutrients (vitamins and minerals) to largely consumed foods or condiments to increase their nutritional value and deliver public health benefits, particularly by meeting the nutritional requirement for added micronutrients without incurring health risks.

In other words, as much as delivering micronutrients to the populace is crucial, policymakers must ensure that policies and implementation programmes for fortification align with the country’s public health aspirations, such as the reduction of diet-related noncommunicable diseases (NCDs).

One such example of this scenario is the case of salt iodisation, which, while preventing iodine deficiency, could inadvertently increase sodium consumption. Consequently, nutrition authorities may and, as a result, need to consider strategies that maintain the benefits of iodine fortification while also mitigating the health risks associated with higher sodium consumption.

In Nigeria, there are ongoing efforts to fortify bouillon cubes with iron as a measure to address the country’s significant anaemia burden. However, there are concerns that this could lead to negative health outcomes when public health is not the crux of the fortification programme.

Given that Nigeria already has a salt fortification programme designed to deliver iodine to the population, the decision to fortify both salt and bouillon – two high-sodium foods – introduces potential health risks. What this means is that this approach will compel Nigerians to increase their sodium intake to obtain essential nutrients like iodine and iron, potentially conflicting with the nation’s sustainable development goals (SDGs) to reduce sodium consumption and fight its rising burden of cardiovascular diseases and hypertension.

Rather than worsening Nigeria’s NCDs burden by fortifying multiple foods containing injurious amounts of sodium, policymakers and those in charge of driving this new fortification agenda should consider global best practices. Specifically, the double fortification of salt with iodine and iron, as is the practice in the USA and India, has proven effective in reducing anaemia rates without increasing dietary sodium intake.

This food fortification wins in other countries stands in stark contrast to Nigeria’s past two decades of mandatory food fortification programme of salt, wheat flour, sugar, and edible oils, which, according to the National Food Consumption and Micronutrient Survey (NFCMS) 2021, has had limited impact, with widespread malnutrition persisting, particularly among vulnerable groups such as women of reproductive age and children.

The NFMCS findings reflect that the challenge of lack of impact is attributable to various factors such as low consumer demand for fortified foods, poor compliance of the food industry in the absence of government incentives, commoditisation and poor stability of micronutrient premixes, paucity of funding for local research activities and training, as well as inadequate regulatory oversight, all of which are necessary for program sustainability and ownership.

Additionally, the NFCMS report confirmed that Nigerians consume more locally made unprocessed staples than fortified or processed alternatives. For example, more Nigerians consume locally milled grains than fortified wheat or corn flour because it is cheaper and accessible. Moreso, the report noted that the average Nigerian adult consumes about 67 grams of rice daily and only 4 grams of bouillon.

Given the prevalent consumption of rice, a staple in the Nigerian diet, fortifying rice with iron could offer a more viable solution for addressing deficiencies like anaemia with minimal health risks compared to bouillon. This strategy is not without precedent. Countries like Brazil have recorded remarkable success in adopting this fortification approach, underscoring the effectiveness of leveraging a staple food such as rice to address nutritional deficits.

Furthermore, it is imperative that, in addition to existing nutrition programmes, the Nigerian government intensifies efforts to review its food policies and enhance agriculture-sensitive nutrition interventions to facilitate the availability and accessibility of safe and nutritious foods for all Nigerians.

Without such critical efforts, food fortification can inadvertently transform from a public health agenda into a market strategy to promote the consumption of ultra-processed foods for profit, as evidenced by recent incidents where a popular children’s chocolate breakfast beverage, marketed as beneficial for brain development, was found to contain harmful sugar levels of sugar capable of increasing the risk of obesity and diabetes among children.

In the same vein, when seasoning cube (bouillon) manufacturers advertise bouillon, they will tell consumers that the product is fortified with iron to manage anaemia but fail to add that it contains high quantities of salt or sodium, which is bad for the heart and blood pressure. Regrettably, this marketing strategy will not only increase demand for the product, but it will also expose consumers to potential health risks, exacerbated by existing regulatory gaps in Nigeria that do not address inadequate product labelling and accurate nutritional declaration that prevents consumers from making informed choices. Unlike in the United Kingdom, where front-of-pack warning labels are implemented for consumers to make informed and possibly healthy food choices.

The Nigerian government, through the Federal Ministry of Health and Social Welfare (FMOHSW) and other competent agencies, have a responsibility to safeguard the health of Nigerians. For emphasis, fortifying bouillon in addition to salt contradicts Nigeria’s sustainable development goal of reducing its population’s sodium intake by 30 percent within the next five years. There are also the added risks that the burden of NCDs will further increase, work productivity will drop drastically, national sodium reduction efforts will be counterproductive, and expenditures on health care will rise significantly.

Considering these issues, it is important that regulatory bodies such as the FMOHSW, National Agency for Food and Drug Administration and Control (NAFDAC), Standard Organisation of Nigeria (SON), and Federal Competition and Consumer Protection Commission (FCCPC) collaborate to monitor national fortification programmes to ensure compliance with global standards and best practices, especially in the selection of food vehicles.

It is also important for the different ministries, departments and agencies coordinating nutrition, food safety, and consumer protection programmes to work together to closely ensure that food policy decisions are well scrutinised to align with overall sustainable development goals as well as national objectives on nutrition and public health, as this will help to ease Nigeria’s rising burden of NCDs. The lives of millions of Nigerians depend on these policy decisions. Hence decision makers and public health authorities must do all they can and in good conscience to save lives!

By Bukola Olukemi-Odele

Odele, a food scientist, is the Programme Officer, Sodium Reduction at Corporate Accountability and Public Participation Africa (CAPPA)