PHC began work in Honduras in 2000, and has now largely completed its mission.
Assessing Food Flows
Honduras had been fortifying certain foods long before PHC came on the scene. Most notably, salt has been fortified since the 1960s and sugar since the 1970s, however deficiencies persisted. Sixty five percent of children 1 – 6 years of age and 19% of women of reproductive age were iron deficient. Goiter affected approximately 5% of school children, and vitamin A deficiency affected 13% of children under 5. Clearly, a revised approach was needed.
To understand what the primary needs were in Honduras, PHC took a “blank slate” approach, looking at facts on the ground, rather than working only within the constraints of historical fortification efforts.
The first step was to understand imports, exports, the dominant crops, and which staple foods were potential fortification vehicles. Although there is trade with neighboring countries, with the exception of rice (of which ~80% is imported from the United States), the bulk of Honduran staple foods are produced domestically.
Given the extent of domestic food production, the second step was to assess the structure of the food processing industry. PHC conducted a series of interviews during the spring of 2009, and the findings were encouraging. Although there were many small artisanal producers of salt and more than twenty rice millers, both were organized in associations, greatly facilitating coordination. Even better, there were only a handful of commercial producers of the other staple foods, most already familiar with fortification.
Unfortunately, millers conjectured that most maize tortillas (a cornerstone of the Honduran diet) were not made of commercially processed maize flour, but from masa nixtamalizada — maize treated with lime and wet-ground in the home or a small village mill.
Once potential food vehicles had been identified, the next step was to assess which had the potential to reach the largest number of people. To that end, PHC partnered with the Ministry of Health to design and carry out a national survey from May to June of 2009. Local surveyors visited some 1,600 households throughout the country and interviewed approximately 1,000 women of reproductive age and 1,000 children under five (the two groups most vulnerable to micronutrient deficiencies). Data on men’s consumption was also collected as a reference point.
In addition to coverage and consumption, the survey also assessed storage and cooking practices that might impact micronutrient retention. Village millers and retail proprietors were interviewed to gather information on food prices and availability, as well as the supply chain for different items.
The consumption survey generated a number of findings. Salt consumption, for instance, was far higher than expected, meaning the previous level of fortification was potentially delivering too much iodine, posing a risk of hyperthyroidism and other deleterious effects. Rice, although widely consumed, was not the primary source of carbohydrates; the average amount eaten on a daily basis was low enough that fortification wouldn’t be feasible.
While neither vegetable oil nor margarine were widely consumed, manteca (a vegetable-fat spread akin to shortening) was extremely common, meaning the potential existed to deliver vitamin A (a fat soluble vitamin) in a second, extremely cost-effective vehicle. While virtually all respondents reported consuming maize tortillas, only a fraction were made from commercially processed flour. As the large millers had suggested, the bulk were made from masa nixtamalizada thus exceedingly difficult to fortify.
Young children disproportionately consumed milk, raising the possibility of fortification targeted specifically to their nutritional needs. The degree to which centrally processed foods had penetrated to even remote villages, and the rapid turnover reported by retailers laid to rest concerns about micronutrient retention.
Lobbying for Change
Although Honduras had long since adopted fortification of salt and sugar, the way in which it had been achieved (by congressional acts that specified exact fortification levels and penalties for noncompliance) left no room for modification based on changes in diet and nutritional science, and gave the Ministry of Health only limited power to enforce fortification.
In parallel with the effort to gather data on consumption, PHC worked with the congressional committee on women and children to draft the Ley de Fortificación de Alimentos en Honduras (Honduras Food Fortification Law), which gives the Ministry of Health the ability to declare fortification of foods mandatory for the public good, the power to enforce that decision, and the flexibility to revise fortification levels without the need for an act of congress. Following tireless lobbying, in November of 2010, the National Congress formally approved the bill. After being signed by President Porfirio Lobo Sosa, it was published and became law in February 2011.
Part of a Regional Movement
As part of support for fortification in Honduras, beginning in 2007 PHC and the Ministry of Health also engaged with the Bien Público Regional (Regional Public Good) initiative, a project promoting harmonization of both fortification standards and monitoring systems. With support from PHC, Honduras took the lead in piloting industry quality assurance and quality control manuals adapted by the initiative.
Now, with the Ministry of Health empowered by the new law, Honduras is working directly with the regional initiative to craft new standards that take into account both current consumption patterns and the need to streamline growing intra-regional trade.
PHC has left Honduras with the tools and capabilities to monitor and maintain their food fortification program without material outside assistance.