#FFI20: Reynaldo Martorell
Robert W. Woodruff Professor of International Nutrition at Emory University Rollins School of Public Health
FFI: How did you become interested in nutrition?
Martorell: I came to nutrition because I was interested in child growth. My PhD (University of Washington) was in biological anthropology and my focus was on the interplay of genetics, infection, and nutrition in shaping child growth. This interest came from earlier in my life. Part of my childhood was spent in banana plantations in Honduras. It was very apparent to me that the children of the US managers were a lot taller than us local kids and I wondered why. For my dissertation I used data from Guatemala to quantify the impact of childhood infections, notably diarrheal diseases, on child nutrition and growth.
FFI: What inspired you to become involved with food fortification?
Martorell: My work suggested that diarrheal diseases were an important factor behind the short stature of impoverished populations, along with deficient dietary intakes. I stayed on as a researcher at the Institute of Nutrition of Central America and Panama (INCAP) and witnessed how a biochemist, Dr. Guillermo Arroyave, passionately combined research, and advocacy to successfully establish the fortification of sugar with vitamin A. A rigorous evaluation showed a significant contribution to vitamin A intakes, a notable reduction in vitamin A deficiency, a substantial increase of vitamin A in breastmilk and increased liver stores. This cemented my interest in fortification as a powerful intervention. From INCAP, I began an academic career in the United States, initially at Stanford, then Cornell and now at Emory, where I have worked on several areas of nutrition, including fortification.
FFI: How is your organization prioritizing fortification?
Martorell: Latin America is the region of developing countries where food fortification has achieved greater coverage and success. Mandatory fortification of wheat flour is the norm, and, in some countries, there is additional legislation for the fortification of maize flour and/or rice. There are many factors that explain this and key among these is the fact that the region has a strong, modern milling industry. Wheat flour production, for example, is highly centralized, facilitating fortification.
FFI: What health outcomes do you expect fortification to improve globally?
Martorell: The impact that fortification may have is, of course, a function of what nutrients and fortificants are added and in what amounts. Some programs, such the fortification of oil with vitamin A, impact a narrow set of outcomes, clinical eye signs and vitamin A deficiency, but others will have broader impact. The national fortification program in Costa Rica requires a diverse set of foods to be fortified with a wide array of micronutrients. But not all potential outcomes are equally valued and measured. In Costa Rica as in many other countries, anemia is a salient concern for policy makers. In Chile, wheat flour fortification with folic acid was valued for the prevention of neural tube defects. Although decision makers will be motivated by one or more outcomes, program designers should also work to correct other deficiencies. Addressing anemia illustrates the need for a comprehensive approach. The preventable causes of anemia are multi-factorial and include infections (malaria, hookworm, HIV) and deficiencies in several micronutrients that can be added to staple foods, including iron, zinc, folate, vitamin B12, and vitamin A.
FFI: In your experience, what are the main components to a successful fortification program?
Martorell: Daniel López de Romaña and I wrote a paper exactly on this topic, using information from three successful fortification programs in Guatemala (vitamin A in sugar), Costa Rica (iron in different foods) and Chile (folic acid in wheat flour). All three programs had strong and well documented impact on nutrient intakes, nutrient biomarkers, and nutritional outcomes (reductions in Vitamin A deficiency, iron deficiency and anemia, and neural tube defects, respectively). We found that institutional research capacity and champions of fortification played a key role in establishing the programs and sustaining them. Private/public partnerships (industry, government, academia, and civil society) were also key for sustainability. We attributed the significant impact of these programs to the use of fortification vehicles that were consumed by the nutritionally vulnerable and were fortified with bioavailable fortificants at adequate content levels in order to fill dietary gaps and reduce micronutrient deficiencies. Finally, adequate monitoring and quality control were essential to maintain fidelity of implementation.
FFI: What are the greatest challenges you have encountered in planning or implementing fortification programs? And how did you address those challenges?
Martorell: My involvement with fortification programs has been in evaluation research, policy guidance, and advocacy. In terms of evaluation research, a major issue I have encountered is funding; evaluations, and particularly rigorous ones, are seldom planned at the beginning, when programs are being designed. This is a problem with programs in general and not just fortification. I have had mixed success with obtaining funding. One has to look for opportunities and be persistent and persuasive. In terms of policy and advocacy, decision makers are generally receptive to food fortification, but a supportive environment and funding is required to start or modify a program.
FFI: What can we do as a society to continue strengthening fortification efforts?
Martorell: Data, data, data but make it known. At the very least, we need to inform the public and policy makers in countries of interest about three things: evidence of micronutrient deficiencies afflicting the population and their consequences, the nutrient gaps in dietary intakes and the proven potential of fortification of commonly staple foods. Civil society, including organizations interested in particular conditions, as well as the media can be effective allies. The history of fortification shows the importance of country champions for the establishment of programs.
FFI: If you were not working in nutrition, what do you think you would be doing?
Martorell: My graduate training was interdisciplinary and included a good dose of nutrition. Had I not obtained a scholarship to a university in the US, I hoped to enroll in the national university of Honduras, which is free and where the choices are limited to traditional fields like law, architecture, engineering, and medicine; I considered medicine the least objectionable choice. Quite possibly, I may have specialized in pediatrics and likely have developed an interest in nutrition. All roads lead to Rome, after all.
FFI: Is there anything else you would like to share?
Martorell: FFI is a public/private partnership. FFI provides a setting in which its Executive Management Team—composed of members or observers from the milling industry (Archer-Daniels-Midland Company, Cargill, Inc., International Association of Operative Millers), United Nations organizations (UNICEF, WHO), international nongovernmental organizations (Global Alliance for Improved Nutrition, Nutrition International), the International Federation for Spina Bifida and Hydrocephalus, Emory University and US Centers for Disease Control and Prevention—who sit around the table to discuss with staff how best to carry out the mission of FFI, which is to “champion effective grain fortification so people have the nutrition they need to be smarter, stronger, and healthier”. We do so without barriers and distrust because we all agree that the mission of providing nutrients lacking in diets through the fortification of staple foods is evidence-based and noble. As a nutritionist, the experience of rubbing elbows with industry and doing it amicably is unusual.
This interview is part of the #FFI20 Champions campaign, a celebration of fortification heroes who have helped build a smarter, stronger, and healthier world by strengthening fortification programs over the past 20 years. To read interviews with other champions, visit the #FFI20 Champions campaign homepage.