A new systematic review published in The Journal of Nutrition has found that large-scale food fortification is a highly cost-effective method to reduce global malnutrition. The research, conducted by scientists from the Cochrane Collaboration, the Food Fortification Initiative, Emory University, and TechnoServe, analyzed 56 studies with over 200 economic analyses from 63 countries. More than 40 of these countries are classified as low- and middle-income economies.
Hidden hunger, a form of malnutrition caused by insufficient intake of essential vitamins and minerals, affects millions worldwide. It is particularly prevalent among children and pregnant women. Current estimates suggest that 56% of children aged 6-59 months and 69% of non-pregnant women aged 15-49 years suffer from hidden hunger globally. The problem worsens during periods of food insecurity and rising prices when access to nutritious diets becomes more difficult for vulnerable populations.
The review represents the most comprehensive economic analysis on food fortification to date. Its findings show strong evidence that large-scale food fortification programs deliver significant health benefits relative to their costs.
Among the main cost-effectiveness analyses reviewed, 58% reported incremental cost-effectiveness ratios (ICERs) below $150 per disability-adjusted life year (DALY) averted. In total, 84% had ICERs under $1,000 per DALY averted compared to no fortification. DALY is a measure combining years lost due to ill-health or early death with years lived with disability.
All benefit-cost ratios calculated in the included studies were positive, meaning the monetary benefits outweighed costs in every case. Additionally, six out of eight cost-utility analyses showed that fortification was both less expensive and more effective than not fortifying foods.
The study covered various combinations of nutrients added to staple foods such as wheat flour and condiments like edible oils, sugar, and salt. Vitamin A, vitamin B9 (folic acid), iron, and iodine were among the most commonly fortified nutrients.
Additional analysis based on each country’s gross domestic product (GDP) per capita found that most interventions were well within accepted thresholds for cost-effectiveness: 87% fell within half of GDP per capita; in low- and middle-income countries specifically, 84% were below 35%, while in low-income countries alone, 71% were less than one-fifth of GDP per capita.
Becky Tsang, co-author and Senior Technical Advisor at the Food Fortification Initiative said: "The decision by policymakers to enact or strengthen food fortification programs is influenced by many factors, including costs and cost-effectiveness. Fortification has been championed as a cost-effective nutrition strategy since the Copenhagen Consensus ranked it among the top cost-effective nutrition interventions to prioritize in 2008. Researchers have published many studies since 2008, and we wanted to better understand and interpret their findings. This comprehensive assessment provides a much-needed, updated case for increased investment in and expansion of food fortification initiatives worldwide. The evidence shows that fortification programs consistently deliver exceptional value for money while addressing some of the world's most pressing nutrition challenges."
These results come amid sharp reductions in global aid for health programs after dramatic cuts in funding in 2025—amounting to a loss equal to nearly half ($704 million) of what was provided for malnutrition efforts in 2022 ($1.6 billion). These reductions could increase malnutrition rates worldwide; an estimated additional 2.3 million severely malnourished children may be at risk with potentially up to 369,000 preventable child deaths annually as a result.
The research team was funded by the United States Agency for International Development (USAID) and includes experts across epidemiology, economics, and nutrition fields. While they noted some limitations regarding quality reporting among existing studies on this topic, they emphasized that consistent positive results across different settings provide strong confidence about large-scale food fortification’s effectiveness.
This review supports increasing investment into food fortification as an effective strategy against hidden hunger globally—a recommendation relevant for policymakers facing limited resources but seeking high-impact interventions.
