The global market for fortified complementary infant foods:

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

William A. Masterswith Winnie Bell and Marc Nene

Friedman School of Nutrition Science and Policy, Tufts Universityhttp://sites.tufts.edu/willmasters | http://www.nutritioninnovationlab.org

29th International Conference of Agricultural Economists, MilanSymposium 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

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.

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?

Many factors could cause this patternof onset and duration

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

• ...and also inadequate total nutrient intake:

6–8 months 9–11 months 12–18 monthsEnergy (kcal) 84% 90% 91%Protein (g) 89% 99% 88%Calcium (mg) 66% 69% 78%Iron (mg) 33% 44% 75%Vitamin A (IU) 535% 663% 443%Vitamin B1 (mg) 59% 67% 60%Vitamin B2 (mg) 48% 50% 35%Niacin (mg) 53% 41% 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.

Mean intake as a percentage of WHO recommended needs, by age

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?

Accra, Ghana (2010)

Low-income country markets arestill dominated by Nestle’s Cerelac

There are many alternatives:

Kenya MaliSenegal

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:

Tanzania

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– 3rd-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

380

400

420

440

460

En

erg

y d

ensi

ty (

kca

l/10

0g d

ry m

atte

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Benin

Botsw

ana

Burkin

a Fas

o

Camer

oon

China

Cote

d'Ivo

ire

DR Con

go

Ethio

pia

Ghana

Haiti

Indo

nesia

Kenya

Mad

agas

car

Mala

wiM

ali

Mau

ritan

ia

Mor

occo

Nepal

Rwanda

Seneg

al

South

Afri

ca

Ugand

a

Energy density by country of purchaserelative to the WFP SuperCereal+ benchmark

Energy density varies widely within and across countries

For now:Results from 109 products in 22 countries

01

02

03

04

0P

rote

in c

ont

ent (

g/10

0g d

ry m

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Benin

Botsw

ana

Burkin

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oon

China

Cote

d'Ivo

ire

DR Con

go

Ethio

pia

Ghana

Haiti

Indo

nesia

Kenya

Mad

agas

car

Mala

wiM

ali

Mau

ritan

ia

Mor

occo

Nepal

Rwanda

Seneg

al

South

Afri

ca

Ugand

a

Protein content by country of purchaserelative to the WFP SuperCereal+ benchmark

05

10

15

20

Fat

co

nten

t (g/

100g

dry

ma

tter)

Benin

Botsw

ana

Burkin

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Camer

oon

China

Cote

d'Ivo

ire

DR Con

go

Ethio

pia

Ghana

Haiti

Indo

nesia

Kenya

Mad

agas

car

Mala

wiM

ali

Mau

ritan

ia

Mor

occo

Nepal

Rwanda

Seneg

al

South

Afri

ca

Ugand

a

Fat content by country of purchaserelative to the WFP SuperCereal+ benchmark

Macronutrients typically fall short of international standards

For now:Results from 109 products in 22 countriesZinc and Iron also often fall short of international standards

02

04

06

0Ir

on c

ont

ent (

mg/

100g

dry

ma

tter)

Benin

Botsw

ana

Burkin

a Fas

o

Camer

oon

China

Cote

d'Ivo

ire

DR Con

go

Ethio

pia

Ghana

Haiti

Indo

nesia

Kenya

Mad

agas

car

Mala

wiM

ali

Mau

ritan

ia

Mor

occo

Nepal

Rwanda

Seneg

al

South

Afri

ca

Ugand

a

Iron content by country of purchaserelative to the WFP SuperCereal+ benchmark

05

10

15

20

Zin

c co

nten

t (m

g/10

0g d

ry m

atte

r)

Benin

Botsw

ana

Burkin

a Fas

o

Camer

oon

China

Cote

d'Ivo

ire

DR Con

go

Ethio

pia

Ghana

Haiti

Indo

nesia

Kenya

Mad

agas

car

Mala

wiM

ali

Mau

ritan

ia

Mor

occo

Nepal

Rwanda

Seneg

al

South

Afri

ca

Ugand

a

Zinc content by country of purchaserelative to the WFP SuperCereal+ benchmark

For now:Results from 109 products in 22 countries

Energy density depends mainly on fat content

02

04

06

08

01

00

380 400 420 440 460Energy density (kcal/100g dry matter)

Fat content (g/100g dry matter) Protein content (g/100g dry matter)Carbohydrate content (g/100g dry matter)

Macronutrients by level of energy densityrelative to WFP SuperCereal+ benchmark levels

For now:Results from 109 products in 22 countries

For zinc and iron, both typically fall below international standards0

51

01

52

0Z

inc

cont

ent (

mg/

100g

dry

ma

tter)

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

Zinc content by level of iron contentrelative to WFP SuperCereal+ benchmark levels

Packaging lists the product’s energy content for 75 products in 18 countries

Actual energy content often exceeds labelled energy, and varies less3

003

504

004

505

00A

ctua

l en

erg

y d

ensi

ty (

kca

l/10

0g

300.00 350.00 400.00 450.00Labeled energy density (kcal/100g)

Energy density by labeled value

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

01

02

03

04

0A

ctua

l pro

tein

co

nten

t (g/

100g

dry

ma

tter)

5.00 10.00 15.00 20.00 25.00 30.00Labeled protein content (g/100g dry matter)

Protein content by labeled value

05

10

15

20

Act

ual f

at c

onte

nt (

g/1

00g

dry

mat

ter)

0.00 5.00 10.00 15.00 20.00Labeled fat content (g/100g dry matter)

Fat content by labeled value

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

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

02

04

06

0A

ctua

l iro

n co

nte

nt (

mg

/100

g dr

y m

atte

r)

0.00 10.00 20.00 30.00 40.00 50.00Labeled iron content (mg/100g dry matter)

Iron content by labeled value

To remedy this market failure, would need quality assuranceIts 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 stickers3) Roll out billboards and demonstrations at randomly-chosen

market locations4) Use household surveys and growth monitoring to track food

purchases & infant bodyweights5) Use child’s age at the time of market advertisements to identify

causal effect of certification on growth

but they usually don’t

Conclusions: These products can have adequate nutrients

AcknowledgementsFor 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!