The global market for fortified complementary infant foods:

Evidence from 108 locally-produced, commercially marketed products in 22 countries

William A. Masters

with Winnie Bell and Marc Nene Friedman School of Nutrition Science and Policy, Tufts University http://sites.tufts.edu/willmasters | http://www.nutritioninnovationlab.org

29th International Conference of Agricultural Economists, Milan

Symposium on Nutritional Gains for the Poor from Agri-food Value Chains

10 August 2015

Much of the world’s growth faltering is experienced by infants during complementary feeding from 6 to 24 months of age

Mean z scores relative to WHO standards across 54 DHS/MCIS studies, by age (1-59 mo.)

What can explain the sudden and severe shortfalls during this period?

Source: CG Victora, M de Onis, PC Hallal, M Blössner and R Shrimpton, “Worldwide timing of growth faltering: revisiting implications for interventions.” Pediatrics, 125(3, Mar. 2010):e473-80.

Many factors could cause this pattern of onset and duration

• • For example: – Exposure to water-borne pathogens, air pollution etc.

– Expression of gestational deficits ...and also inadequate total nutrient intake:

Mean intake as a percentage of WHO recommended needs, by age Energy Protein Calcium Iron Vitamin A Vitamin B1 Vitamin B2 Niacin

(kcal) (g) (mg) (mg) (IU) (mg) (mg) (mg)

6–8 months

84% 89% 66% 33% 535% 59% 48% 53%

9–11 months

90% 99% 69% 44% 663% 67% 50% 41%

12–18 months

91% 88% 78% 75% 443% 60% 35% 44% Note: Data shown are mean values for a sample of 400 children in Eastern Ghana.

Source: C.A. Nti and A. Lartey (2007). “Young child feeding practices and child nutritional status in rural Ghana.” International Journal of Consumer Studies, 31: 326-332.

Why might sufficient nutrient intake be difficult to achieve?

• Total quantity is small and inexpensive relative to family budget • • • ...but nutrient density and digestibility must be higher than family diet Complementary foods have high-cost ingredients and processing – – – Starchy staple must be fortified with protein, fats and micronutrients Processing at home using traditional methods is labor intensive Availability from artisanal or industrial manufacturers is limited Since Incaparina in the 1960s, donors have funded startups to produce and sell high-quality complementary foods at lowest possible cost – – Many different recipes and production methods are possible Locally-adapted products are readily acceptable, have proven efficacy, and cost much less than either home production or imports from industrialized countries So what products do we now see in places with widespread malnutrition?

Low-income country markets are still dominated by Nestle’s Cerelac

Accra, Ghana (2010)

There are many alternatives:

Generics, e.g. “weanimix” in Ghana: Many small-scale local start-ups, e.g. these from around Africa: And various multinationals, typically sold in supermarkets and pharmacies:

Cameroon

• •

This project asks:

What’s for sale, and is it any good?

A global catalog of marketed complementary foods: – Step 1: Invite collaborators to identify products on local markets in 2014 • Criterion: marketed as complement to breastmilk, for >6 months of age • Typical product: a fortified composite flour – Step 2: Pay them to send us a random sample for nutrient testing • Goal: at least 20 countries, averaging 5 products from each country • Test for protein, fats, calories, iron, zinc, and phosphorus (for phytates) – Step 3: Test predictions from the economics of product quality • Hypothesis: Consumers cannot detect nutrients, so composition will vary widely • Remedy would be third-party quality assurance If products can be good but often aren’t, quality assurance can help – – – both plant inspections and product sampling with nutrient testing 3 rd -party label, e.g. “INQAP—OK for babies over 6 months” local advertising to establish this third-party brand

For now:

Results from 109 products in 22 countries Energy density varies widely within and across countries

Energy density by country of purchase relative to the WFP SuperCereal+ benchmark B en in B ot swa B ur na ki na F as o Ca m er oo n Ch in Co a te d 'Iv oi re DR Co ng o E th io pi a G ha na Ha iti In do ne si a K en M ya ad ag as ca r M al awi M al M i au rit an ia M or oc co Ne pa l Rw an da S en eg S al ou th A fri ca Ug an da

For now:

Results from 109 products in 22 countries Macronutrients typically fall short of international standards

Protein content by country of purchase relative to the WFP SuperCereal+ benchmark Fat content by country of purchase relative to the WFP SuperCereal+ benchmark B en in B ot swa B ur na ki na F as o Ca m er oo n Ch Co in a te d 'Iv oi re DR Co ng o E th io pi a G ha na Ha iti In do ne si a K en M ya ad ag as ca r M al awi M al M i au rit an ia M or oc co Ne pa l Rw an da S en eg S al ou th A fri ca Ug an da B en in B ot swa B ur na ki na F as o Ca m er oo n Ch Co in a te d 'Iv oi re DR Co ng o E th io pi a G ha na Ha iti In do ne si a K en M ya ad ag as ca r M al awi M al M i au rit an ia M or oc co Ne pa l Rw an da S en eg S al ou th A fri ca Ug an da

For now:

Results from 109 products in 22 countries Zinc and Iron also often fall short of international standards

Zinc content by country of purchase relative to the WFP SuperCereal+ benchmark Iron content by country of purchase relative to the WFP SuperCereal+ benchmark B en in B ot swa B ur na ki na F as o Ca m er oo n Ch in Co a te d 'Iv oi re DR Co ng o E th io pi a G ha na Ha iti In do ne si a K en M ya ad ag as ca r M al awi M al M i au rit an ia M or oc co Ne pa l Rw an da S en eg S al ou th A fri ca Ug an da B en in B ot swa B ur na ki na F as o Ca m er oo n Ch Co in a te d 'Iv oi re DR Co ng o E th io pi a G ha na Ha iti In do ne si a K en M ya ad ag as ca r M al awi M al M i au rit an ia M or oc co Ne pa l Rw an da S en eg S al ou th A fri ca Ug an da

For now:

Results from 109 products in 22 countries

Macronutrients by level of energy density

Energy density depends mainly on fat content

380 400 420 440 Energy density (kcal/100g dry matter) 460 Fat content (g/100g dry matter) Carbohydrate content (g/100g dry matter) Protein content (g/100g dry matter)

For now:

Results from 109 products in 22 countries

Zinc content by level of iron content

For zinc and iron, both typically fall below international standards

0 20 40 Iron content (mg/100g dry matter) 60

Packaging lists the product’s energy content for 75 products in 18 countries Actual energy content often exceeds labelled energy, and varies less

Energy density by labeled value 300.00

350.00

400.00

Labeled energy density (kcal/100g) 450.00

Note: the WFP’s SuperCereal Plus has minimum energy content of 410 kcal/100g

Packaging lists protein for 77 products and fat for 72 products, both in 19 countries Both protein and fat typically fall short at the higher labeled values

Protein content by labeled value Fat content by labeled value 5.00

10.00

15.00

20.00

25.00

Labeled protein content (g/100g dry matter) 30.00

0.00

5.00

10.00

15.00

Labeled fat content (g/100g dry matter) 20.00

Note: the WFP’s SuperCereal Plus has minimum fat content of 9 g/100g, and minimum protein content of 16 g/100g.

Packaging lists iron for 53 products in 17 countries Iron content is widely scattered around labeled values

Iron content by labeled value 0.00

10.00

20.00

30.00

40.00

Labeled iron content (mg/100g dry matter) 50.00

Note: the WFP’s SuperCereal Plus has minimum iron content of 12.5 g/100g.

Conclusions: These products can have adequate nutrients but they usually don’t

To remedy this market failure, would need quality assurance Its effectiveness could be measured by an RCT: 1) Establish an Infant Nutrition Quality Assurance Project (INQAP) 2) Recruit manufacturers to participate, and issue time limited INQAP-OK stickers 3) Roll out billboards and demonstrations at randomly-chosen market locations 4) Use household surveys and growth monitoring to track food purchases & infant bodyweights 5) Use child’s age at the time of market advertisements to identify causal effect of certification on growth

Acknowledgements

For funding: USAID, for an International Food Policy Research Institute Linkage Grant and the Feed the Future Nutrition Innovation Lab .

For samples: Ambroise Agbota, Jean-Paul Anoh, Mahaman Bamba, Aaron Cheng, Gnangbo Christian, Amelia Darrouzet-Nardi, Claude Emile, Issa Fadiga, Matt Hazel, Dorothy Nzembi Kimanthi, Yolande Kouame, Emmanuel Kouame, Rachid Laajaj, Perrine Loock, Janeen Madan, Will Masters, Menno Mulder-Sibanda, Fatouman Ouattara, Galase Ramolefhe, Marianne Santoso and Robin Shretha. For testing: Midwest Labs, Omaha.

Thank you!