EMT Meeting Minutes
6-7 April 2022
Atlanta, GA, USA and virtual
EMT Members in Attendance
● Jane Friedrich, Cargill, Inc. (v)
● Manpreet Chadha, Nutrition International (NI) (v)
● Markus (Mark) Lotsch, ADM
● Melinda Farris, International Association of Operative Millers (IAOM)
● Penjani Mkambula, Global Alliance for Improved Nutrition (GAIN) (v)
● Reynaldo (Rey) Martorell, Emory University
● Sylvia Roozen, International Federation for Spina Bifida & Hydrocephalus (IF) (v)
● Vilma Tyler, UNICEF
EMT Observers
● Jennifer Williams, US Centers for Disease Control and Prevention (CDC) National Center on Birth Defects and Developmental Disabilities
● Luz Maria De-Regil, World Health Organization (WHO) (v)
● Ruth Petersen, CDC National Center for Chronic Disease Prevention and Health Promotion (v)
Guests
● Cara Mai, CDC National Center on Birth Defects and Developmental Disabilities (v)
● Godfrey Oakley, Center for Spina Bifida and Hydrocephalus, Emory University
● Jorge Rosenthal, CDC National Center on Birth Defects and Developmental Disabilities (v)
● Rafael (Rafa) Flores-Ayala, CDC National Center for Chronic Disease Prevention and Health Promotion (v)
● Yan Ping Qi, CDC National Center on Birth Defects and Developmental Disabilities (v)
● Usha Ramakrishnan, Emory University
Staff: Jessie Genoway, Nada Elhusseiny, Parveen Bhalla, Ronald Afidra, Sandra King, Scott Montgomery, Venkat Subramanian, and Wilson Enzama
(v) = virtual
Introductions and Approval of November 2021 Minutes
EMT members approved the November 2021 minutes.
Strategic Plan Overview
As a review for EMT members, Scott presented FFI’s strategic plan to scale up large-scale cereal grain fortification. The presentation provides an overview of FFI’s four phases of work: explore and engage, map the context, design and develop, and monitor for compliance and impact. These phases will be covered in regional presentations.
Parveen presented updates from the state of Haryana, including the phase-3 assessment of the Haryana demonstration project to assess the impact of fortified atta on various biomarkers of micronutrient status (hemoglobin, ferratin, red blood cell folate, serum folate, and vitamin B12) in women living in two blocks that have been producing flour fortified to the 2016 fortification standards (report is expected in May 2022), FFI’s partnership with NI through the Fair Price Shop assessment to determine the coverage and acceptability of fortified foods sold in the shops, technical assistance to millers in partnership with the Haryana State Co-operative Marketing and Supply Federation (HAFED) to ensure quality fortified flour is consistently produced, and efforts to revert the 2018 national-level fortification standards to the 2016 standards.
Venkat presented updates on work in Maharashtra state (direct advocacy with the state government to establish a foundation for a future state fortification program through the Public Distribution System (PDS) and/or Integrated Child Development Services (ICDS)), Madhya Pradesh state (exploring opportunities to support rice and wheat flour fortification with partners), and Gujarat state (exploring opportunities to start a state-wide fortification program). Other updates include the development of the India technical support team to reach large audiences, create fortification resources, and collaborate with research organizations.
Venkat emphasized the importance of developing robust fortification programs and systems that can withstand pressures like those presented during the COVID-19 pandemic.
Jennifer commented that a manuscript describing phase-1 of the Haryana Demonstration Project, the assessment of baseline folates, should be published in the next few months. As Parveen mentioned, the Post Graduate Institute of Medical Education & Research, Chandigarh, is analyzing blood folates from the phase-3 assessment. Scott asked if there was preliminary data from phase-3 available. Jennifer responded no, the results are not yet clear.
Manpreet commented that NI is assessing the feasibility of food fortification in Uttar Pradesh state. NI seeks to uncover the nutrition interventions that are ongoing and how fortification can fit within these interventions to fill dietary gaps. NI is using a national nutrition assessment from 2012, which is unfortunately only based on one 24-hour recall. On the whole, quality dietary data in India is unavailable, and this is unfortunately not helpful for reinstating the 2016 standards. NI hopes that their new research can be helpful.
Rafa commented that the India staff’s presentation of their approach to fortification in various states was helpful and clear. Rafa asked if there was data on the coverage of fortification in Haryana available. He asked Venkat to elaborate on the quality issues mentioned during the presentation.
To answer Rafa’s first question on coverage, Parveen responded that more than 95% of people in the Haryana blocks studied con
sumed an average of 150 grams per person per day of fortified atta (wholemeal wheat flour), implying that fortification of atta would be able to make a health impact.
To answer Rafa’s question on the quality issues that FFI has found in Haryana, Venkat commented quality problems start with the grain that comes from farmers and continues through the milling and regulatory processes. India does not have a proper regulatory system for monitoring the quality of fortified foods. The only criteria that is measured for quality is weight. Oftentimes, millers will add water and other products that produce poor atta. Regulators don’t enforce standards or are corrupt. Venkat estimates that around 60% of final fortified flour is substandard.
Scott added that FFI has worked closely with HAFED to encourage millers to incorporate quality standards. He added that the reason local partners have not scaled up fortification in the remaining five districts in Haryana is due to challenges within the government. In an effort to scale up fortification despite these challenges, FFI has established a coalition of millers to advocate to the government.
Wilson provided an overview of FFI’s work in Africa through Smarter Futures, which ended in December 2021, and other non-Smarter Futures supported countries in the Southern African Development Community (SADC) region. Wilson also presented updates on work in Botswana and Mauritius through a recent grant to FFI from the Food and Agriculture Organization of the United Nations (FAO).
Penjani asked why FFI considered Mozambique to be in the monitoring for compliance and impact stage. Wilson responded that with the rollout of FortifyMIS in the country, there would be compliance data available, pushing the country into the monitoring stage. Penjani confirmed that compliance data will become available soon.
Manpreet asked if Mozambique was the only country where FortifyMIS is being implemented and if there was any data on its impact on compliance. Wilson responded that no, there is no impact data available. FFI also had a pilot project for FortifyMIS in Uganda. However, the pilot was not successful as there was an issue in connecting the system to that of laboratory information systems and certification information systems already functional in the country. FFI has paused discussions until the government shows interest in remedying the problem. Despite challenges in Uganda, FFI hopes to gather data on FortifyMIS’s impact in Mozambique, where there has been strong support for the system.
Penjani added that GAIN is implementing FortifyMIS in Nigeria and Tanzania with the Tanzania Bureau of Standards. Penjani hopes that industry data will be generated from regulators.
Vilma updated the EMT that millers in Morocco had reached out to a premix company with complaints that the premix the company supplies does not comply to the national standard. In fact, Morocco’s standards are not realistic to implement. Morocco wants UNICEF and FFI’s support to strengthen the quality of its wheat flour, fortification standards, regulatory enforcement, and the organization that monitors all food products. Though Scott has been in contact with the premix company to assess the problem, FFI is not yet fully engaging stakeholders in Morocco. FFI plans to engage once priority activities in Egypt are completed.
Jennifer asked why the fortification standards in Morocco were facing challenges. Vilma responded that the fortification standard the ministry created when updating (to be in alignment with WHO standards) does not work. A non-technical person wrote the standard specifying the grams per metric ton of premix to be added including vitamins, minerals, and the carrier. The specified combination of these ingredients is not possible to achieve by the premix supplier. Scott added that when setting standards, a country should specify the parts per million of vitamins and minerals to be in the final flour products and leave it to the premix companies to put the exact formula together, including carriers.
Rafa asked why FortifyMIS has trouble being implemented. Wilson responded that, in most countries, the system that FortifyMIS relies on, a reporting framework, does not exist. The second issue is that government regulators do not have devices to report compliance data. Regulators do not want to use their personal phones and they do not have business devices available to use for reporting compliance.
Penjani added that developing the system is the easy part; the cultural and behavioral issues cause the program to languish.
Nada provided an update of efforts in Egypt, including a recap of progress since FFI began working in Egypt since 2019. Nada highlighted a recent workshop for millers and fortification stakeholders that FFI hosted in Cairo in February 2022 with the support of GAIN, IF, UNICEF, and other partners. Additionally, Nada presented that FFI will begin to explore fortification efforts in Algeria, Morocco, and Tunisia.
Rey asked when fortification might be implemented in Egypt and if there are plans for evaluation.
Nada answered that nothing has been officially announced. However, it is expected that, after Ramadan, likely in May 2022, Egypt will launch mandatory fortification of wheat flour.
Rey gave an overview of his proposal for assessing health impact in Egypt. Ideally, FFI would need national dietary 24-hour recall data, though there are other sources that can assess how much fortified flour people are eating. Ideally, FFI would want data for specific populations including mothers, young children, those who live in urban areas, and those who live in rural areas. Rafa and Rey did a similar analysis for Guatemala. If one knows how much fortified flour people are consuming, one can estimate the impact of fortification on nutrient intake.
ACTION: Nada responded that she will look into this more, and that she knows of several national nutrition surveys. Officially, Nada uses the 2014 Demographic Health Survey (DHS). Helena noted that DHS typically do not include dietary intake information.
Rey added that the data/simulation model produced can be published in a journal.
Scott commented that, if we can get permission from MOSIT, FFI could use information collected through beneficiaries’ subsidy card each, which is swiped at points of sale every time the beneficiary buys fortified bread. This data would include information on households as well (to have an idea of the specific population).
ACTION: Nada will follow through with FFI contacts in MOSIT to see if they would be willing share such data.
Rafa added that the World Bank collects the Household Income and Expenditure Surveys (HIES) and that there is a specific group collecting HIES in Africa. Rafa and Rey u
sed HIES for their analysis in Guatemala.
Rafa commented that 80% of wheat comes from Ukraine and Russia—how will the government prevent a shortage of wheat flour in Egypt?
Nada responded that the government had preordered wheat flour before the crisis. Egypt has sufficient supplies for the foreseeable future and the government is encouraging wheat to be produced locally. The government is exploring other countries to import wheat flour from, including Argentina, whose Ambassador to Egypt was present at the recent fortification workshop in Cairo. For now, there is no severe shortage of flour or bread.
Scott added that wheat flour prices are increasing globally, and that the Egypt Government might make changes to the subsidy system (a politically charged issue).
Godfrey mentioned that one evaluation strategy in Tanzania and Chile involved taking venous blood from women and children to analyze blood folate levels before and after fortification. Godfrey emphasized that DHS should take venous blood and/or plasma serum. Historically, DHS only takes a capillary (finger prick) sample.
Nada asked EMT members if their organizations planned to be involved at the upcoming 2022 United Nations climate change summit (COP 27), which will be hosted by Egypt. Specifically, Nada asked if EMT organizations were planning to present flour fortification as a sustainable food intervention at the event.
Jennifer responded that no, CDC is not involved.
Vilma responded that UNICEF is not involved in COP27 from the nutrition side, but she will explore.
Scott provided a snapshot of FFI’s wheat flour fortification efforts across nine countries in Europe. In eight Central Asian countries, FFI hired Jeff Gwirtz to compile supply chain analyses; FFI is currently finalizing and filling in gaps for the analyses. In Tajikistan, David McKee is verifying FFI’s milling analyses in the country. FFI will continue to work with UNICEF, IF, the Center for Spina Bifida and Hydrocephalus, and other partners to move fortification forward in the region. Of note, FFI has begun efforts to explore and engage fortification champions in Turkey to advocate for mandatory wheat flour fortification legislation and standards.
Godfrey provided an overview of the Global Alliance for Prevention of Spina Bifida (GAPSBi-F), a global organization of neurosurgeons and advocates for folic acid fortification. On 4 April 2022, GAPSBi-F hosted a webinar led by a Turkish neurosurgeon. In the webinar, four speakers (including Scott) presented on the importance of folic acid fortification with Turkish stakeholders. At the end of the webinar, several key stakeholders expressed interest in starting a fortification program in Turkey and began planning next steps.
Scott added that FFI is optimistic we can move fortification forward because former roadblocks have been removed. When FFI completed its Europe strategy, FFI found that Turkey provides one of the biggest opportunities for fortification in Europe.
Venkat commented that Indian millers and fortification advocates have connections with Turkey, and could also support where possible.
Jessie presented communication activities that have been completed over the past six months including the 2021 FFI Annual Report, Smarter Futures summary document, webinars, press releases, publications, and funding proposals. She also presented updates on the FFI website and social media metrics.
Jennifer commented that the 30th anniversary of the US recommendation for folic acid is approaching (11 September 2022). CDC Birth Defects is putting together a manuscript to commemorate the anniversary. The manuscript will be published in Annals of Nutrition.
Penjani added that GAIN also has its 20th birthday this year.
Penjani asked why rice fortification was one of the most visited pages on FFI’s website. Jessie responded that it was likely due to increased global interest in scaling up rice fortification, particularly in India (the second largest share of the website’s visitors have IP addresses registered in India).
Manpreet asked if FFI is using Instagram. Jessie replied that yes, FFI has been piloting an Instagram account. The account has less traffic than FFI’s other social media handles, but it is still a useful addition to FFI’s social media portfolio.
ACTION: Jessie will report metrics for Instagram in future EMT meetings.
Rey asked about the FFI 20 Champions campaign. He recommended that FFI be strategic in selecting champions, specifically by including individuals or foundation that have been generous supporters for food fortification.
Vilma commented that, at the 2021 Food Systems Summit, large-scale food fortification (LSFF) was highlighted as an area that needs its communications to be refreshed. Consequently, UNICEF has been exploring strategies to reengage the public around food fortification issues. UNICEF found that 23 countries at the Food Systems Summit engaged with young people who talked about food safety, nutrition, access, etc. and published the Fix My Food report. Vilma suggested that it might be helpful for FFI to engage with voices of youth, people with spina bifida/lived experiences through the FFI 20 Champions campaign.
Godfrey added that FFI should consider including doctors/neurosurgeons in our list of champions as well.
Nada commented that it would be interesting for FFI to host a monthly fortification webinar series.
In her prerecorded presentation, Helena presented five proposed updates to the 2018-2023 FFI strategic plan in response to conversations at the previous EMT meeting. The proposed changes are:
· Indicators 4.3-4.6: Recommend changing proportion of industrially milled maize flour that is fortified from 70% to 35%,
· Indicator 6.1: Recommend changing number of educational institutions with resources to teach fortification from 9 to 5,
· Indicator 6.2: Recommend changing number of individuals trained in fortification-specific topics by FFI staff who report using the information within 6 months of training from ≥ 50 annually to > 20 annually,
· Indicator 8.1:
Recommend changing number of fortification resources developed from 10 to 15 resources per year, and
· Indicator 10.3: Recommend changing from 80,000 to 30,000 FFI website sessions.
After the Executive Discussion, the EMT agreed to the following updates to FFI’s strategic indicators:
· Indicators 4.3-4.6: Recommend changing proportion of industrially milled maize flour that is fortified from 70% to 35%
Updated goal is approved. Add a note to the indicator that provides the previous goal (70%) and explains why and how FFI changed the goal.
· Indicator 6.1: Recommend changing number of educational institutions with resources to teach fortification from 9 to 5
Updated goal is approved. If the FFI strategic plan does not already include, reword the indicator to “number of educational institutions milling schools with resources to teach fortification.” Add a note that FFI does not necessarily teach fortification but develops advocacy materials for milling schools. The EMT also suggested that we might consider reaching out to institutions beyond milling schools to see if they would like to include FFI’s educational materials in their curriculum.
· Indicator 6.2: Recommend changing number of individuals trained in fortification-specific topics by FFI staff who report using the information within 6 months of training from ≥ 50 annually to > 20 annually
Updated goal is approved. Add a note to the indicator that provides the previous goal and explains why FFI changed the goal.
· Indicator 8.1: Recommend changing number of fortification resources developed from 10 to 15 resources per year
Updated goal is approved. Add a note to the indicator that provides the previous goal and explains why FFI changed the goal.
· Indicator 10.3: Recommend changing from 80,000 to 30,000 FFI website sessions.
Updated goal is approved. Add a note to the indicator that provides the previous goal and explains why FFI changed the goal. Continue to track both FFI and Global Fortification Data Exchange (GFDx) website sessions.
The EMT also provided the following general requests:
· In future presentations of the strategic plan, present the former and updated indicator goals along with an explanation of the change.
· When developing the next FFI strategy, consider decreasing the number of indicators and make sure that indicators reflect the strategic goals of FFI’s activities.
ACTION: Helena to update strategic indicators with EMT recommendations.
ACTION: Melinda suggested tracking referring link data (how many users are referred to FFI’s website from the GFDx website and vice versa) via google analytics. Jessie will follow through and present at next EMT meeting along with the website session data.
In her prerecorded presentation, Helena presented updates on FFI’s efforts to generate and collate research projects. Recently published papers include a systematic review of rice fortification by Becky and FFI graduate research assistant Irene Pyo.
Rey emphasized the role of FFI at Emory University is highlighted by Helena’s presentation. FFI is an institution that Emory needs to support and be proud of.
ACTION: Before they can approve/reject, the EMT requests that Helena to provide detail on the purpose, objectives, methodology, and study protocol for the proposed manuscript “Monitoring for Food Fortification: Trends and Strategies”.
Global Fortification Data Exchange (GFDx)
In her prerecorded presentation, Helena updated the EMT on GFDx project objectives and progress toward these objectives. Partners are on course to achieve its objectives. The GFDx is a collaboration among FFI, GAIN, and the Iodine Global Network and is funded by the Bill and Melinda Gates Foundation (BMGF).
Usha asked whether individuals contact the GFDx and if the GFDx can use these metrics as a way to measure engagement with target audiences. Helena responded that, yes, individuals contact the GFDx and that it is possible to use these metrics to measure engagement.
Scott provided an update on the countries FFI supports in the Asia-Pacific region, including the feasibility assessment of rice and wheat flour fortification in Bangladesh (FFI recommends that Bangladesh fortifies wheat flour immediately and take a wait-and-monitor approach for rice fortification) and an assessment of double-fortified salt in India. Scott also provided country updates for Indonesia (out of 9 million metric tons of flour milled, more than half is being fortified according to the revised standards, and NI expects this amount to increase), Malaysia, Mongolia, and Viet Nam. There have been no updates since the last EMT meeting in Papua New Guinea, the Philippines, and Sri Lanka.
Manpreet added that NI has been working to conduct a process evaluation of double-fortified salt in India with FFI’s assistance. FFI is helping to systematically synthesize learning among officials and a qualitative assessment. They plan on wrapping up the assessment mid-2022.
Rey asked whether NI was planning to include specific scientific articles and he committed to send them to Manpreet.
Jennifer asked what Indian states will be included in the evaluation. Manpreet commented that the assessment is national but that they will do a deep-dive in two states: Madhya Pradesh and Uttar Pradesh.
This also led to a discussion about “ultra-processed” food. It was suggested that FFI publish something regarding ultra-processed food. Vilma mentioned that there is a clear definition of ultra-processed foods and she subsequently shared the material with EMT members.
Helena responded that ultra-processed food is one of the topics that will be touched upon in the proposed manuscript on “Monitoring for Food Fortification: Trends and Strategies”.
Manpreet commented that convers
ations with fortification stakeholders and the Government of Bangladesh have been slowed by COVID-19. The Government of Bangladesh’s focus is fortification of rice through the social safety net system. FFI’s assessment has helped the government plan its next steps with their fortification activities.
Usha asked how much of the wheat flour being fortified in Malaysia is used to produce noodles, the country’s most commonly consumed food product that contains wheat flour. Scott and Manpreet responded that around 80% of all fortified flour is used to produce noodles.
Brainstorming Session
FFI 20 Champions Campaign
EMT members nominated the following individuals:
· Omar Dary, USAID
· BMGF because of their investment in fortification and/or Andreas Bluthner, Dipika Matthias
· Vilma Freire
· Science category nominees: RJ Berry, Krista Crider, CDC folic acid task force that started under Godfrey, and CDC IMMPaCt team
· WHO nutrition group (specifically Juan Pablo and/or Luz)
Rey suggested that FFI categorize the champions. Suggested categories include champions in fortification science, investments/funding (e.g. BMGF or Dutch Government), implementation, private industries, partner organizations, FFI strategy indicators (e.g. countries that align standards with WHO standards, mandate legislation, and/or prioritize fortification as a multisectoral strategy).
The EMT suggested that champions are representative from various geographies and sectors.
FFI 20th Birthday Celebration
Expected date: November 2022 EMT meeting.
Usha suggested that FFI have the party in the new Rollins School of Public Health (RSPH) building. FFI plans to invite Dani Fallin, new RSPH Dean.
Jennifer suggested that FFI and CDC partner to celebrate (FFI’s 20th birthday and 30 years since CDC’s folic acid recommendation).
Rey suggested that FFI submit a non-technical narrative of FFI’s history (Rey to follow up with names of journals that might be interested). Helena responded that the Global Secretariat discussed this and decided that staff does not have the bandwidth to produce a scientific publication in addition to the other FFI 20th birthday activities.
EMT members asked if FFI is planning to go to the International Congress of Nutrition in Tokyo, Japan in December 2022, and suggested that FFI could share FFI’s 20th birthday video at that conference. Partners from the GFDx and NI, but no FFI staff, are planning to go to the conference.
Rafa suggested that FFI consider a webinar format for the 20th birthday celebration as a way to broadcast the key achievements and history of FFI.
Fundraising
Scott provided an overview of past, current, and potential funding opportunities.
In response to FFI’s efforts to engage the Children’s Investment Fund Foundation (CIFF), Vilma commented that CIFF will fund maternal nutrition but not necessarily LSFF. UNICEF has found it useful to repackage their messaging toward CIFF to focus on maternal nutrition rather than LSFF. Godfrey also commented that he found it helpful to tailor messaging with donors around United Nations Sustainable Development Goals.
Manpreet suggested that in appeals to Leonie Vierck, FFI’s new program officer at BMGF, FFI focus on proposals the focus on the digitization of food fortification monitoring.
Vilma added that Kiwanis funding for fortification has focused on iodine nutrition and that the amount given to UNICEF has been very small over the years. Currently the board will like to renew their focus on iodine nutrition. However, there is an opportunity to pitch fortification again and Vilma will request from Stan Soderstrom that Godfrey present at their next board meeting. Godfrey commented that a Rotarian from Colombia (Sonya) that he met at the Houston Rotary meeting is hoping to get Rotarians on board for folic acid fortification.
ACTION: Vilma commented that FFI should reach out to Rizwan Yusufali (UNICEF) to initiate the next UNICEF grant. Jessie will follow-up.
Sandra suggested that FFI improve the way it communicates its relationship to Emory, making it clear to potential donors that Emory does not provide FFI with a safety net.
ACTION: Rey suggested that we can better communicate this on the FFI website and to clarify that Emory’s contributions are in-kind and to fund 50% of Rollins Earn and Learn students’ salaries. Jessie will add the suggested text: “Emory contributes office space and administrative support but not core funding to FFI.”
ACTION: The current RSPH dean, James Curran, is retiring from RSPH in June 2022. Danielle (Dani) Fallin, a mental health researcher from Johns Hopkins University, will join RSPH in July 2022. FFI will need to meet with and educate her on FFI’s contribution to RSPH. Sandra suggested that FFI create a package of communication materials and deliver to her.
Godfrey mentioned that FFI should consider fortifying salt with folic acid. Vilma cautioned against this with WHO’s resolution to decrease salt, fat, and sugar intake. Rey added that it is important to have a product that doesn’t change the organoleptic properties of the food.
Manpreet commented that BMGF granted NI funding for a fortified salt project in Ethiopia (product development and market testing). The project seeks to identify critical components that can help bring double-fortified salt (iodine and folic acid) onto the market.
Executive Session Discussion
The next EMT meeting will be 9-10 November 2022.
During the Executive Session discussion, Scott presented FFI’s budget and funding updates. Scott reiterated that, though FFI has core support for the next two years, FFI needs to keep working on fundraising support for activities that scale up fortification globally.
The EMT discussed contracts and the difficulty that FFI is having with Emory administrative activities. Emory is undergoing significant changes and they are aware of the issues that need to be fixed. Usha added that she has heard about these challenges from other staff and faculty. Usha and Rey offered their assistance in helping to push forward contacts when Sandra encounters challenges. Usha reiterated that Emory’s value to FFI is Emor
y’s students and the assistance they can provide.
The EMT expressed thanks to FFI’s staff for the excellent presentations. Jane added her thanks for EMT members that were able to join the meeting in person and virtually.
