nutrients

Article
The Role of Multiply-Fortified Table Salt and Bouillon in Food
Systems Transformation
Dipika Matthias 1, *, Christine M. McDonald 2,3 , Nicholas Archer 4 and Reina Engle-Stone 3

1 Bill & Melinda Gates Foundation, Seattle, WA 98109, USA

2 Departments of Pediatrics, and Epidemiology and Biostatistics, University of California,
San Francisco, CA 94143, USA; christine.mcdonald@ucsf.edu
3 Department of Nutrition and Institute for Global Nutrition, University of California, Davis, CA 95616, USA;
renglestone@ucdavis.edu
4 CSIRO Health and Biosecurity, North Ryde, Sydney 2113, Australia; nicholas.archer@csiro.au
* Correspondence: dipika.matthias@gatesfoundation.org

Abstract: Our global food system lacks the critically needed micronutrients to meet the daily re-
quirements of the most at-risk populations. Diets also continue to shift toward unhealthy foods,
including the increased intake of salt. While most countries exceed the WHO’s recommended levels,
sodium does play an essential physiological role. Table salt and other salt-containing condiments,
such as bouillon, also have cultural importance, as they are used to enhance the flavor of foods
cooked at home. Given their universal consumption across income classes and both urban and rural
populations, these condiments are an integral part of the food system and should, therefore, be part
of its transformation. Fortification of salt and salt-containing condiments can play a catalytic role
in the delivery of population-wide nutritional and health benefits. With relatively consistent levels
of intake across the population, these condiments hold high potential for delivering micronutrients




beyond iodine while also reducing concerns related to high micronutrient intake, particularly so in

 countries where the industries are relatively consolidated. As a flexible and complementary strategy
Citation: Matthias, D.; McDonald, to an evolving food system, fortification levels can also be adjusted over time to ensure micronutrient
C.M.; Archer, N.; Engle-Stone, R. The delivery targets continue to be achieved as the system improves, whether through lower intakes
Role of Multiply-Fortified Table Salt of sodium in line with WHO recommendations, enhanced consumption of nutrient-dense foods,
and Bouillon in Food Systems and/or broader adoption of biofortified crops. Future areas of innovation are required to realize this
Transformation. Nutrients 2022, 14,
vision, including developing affordable salt substitutes to meet cost requirements of consumers in
989. https://doi.org/10.3390/
low-and middle-income countries, improving the stability and bioavailability of the micronutrients
nu14050989
in condiments so that delivery targets can be reached without affecting sensory attributes, and the
Academic Editor: James H. Swain development of efficient systems for monitoring population intake and micronutrient status to inform
Received: 22 January 2022
fortification program design and management. Rather than being considered antithetical to the
Accepted: 23 February 2022 transformation, multiply-fortified salt and bouillon can strengthen our ability to meet the cultural,
Published: 26 February 2022 sensory, nutritional, and health needs of an evolving food system.

Publisher’s Note: MDPI stays neutral

Keywords: salt; bouillon; condiment fortification; fortified foods; micronutrient deficiencies; sodium;
with regard to jurisdictional claims in
large scale food fortification; fortification innovations; food systems; non-communicable diseases
published maps and institutional affil-
iations.

1. Introduction
Copyright: © 2022 by the authors. Over 2 billion people are at risk for micronutrient deficiencies globally [1], a figure that
Licensee MDPI, Basel, Switzerland. has remained unchanged for decades and has only been further exacerbated by the global
This article is an open access article COVID-19 pandemic that has reduced access to micronutrient-rich diets in low-income
distributed under the terms and countries due to disrupted supply chains and diminished incomes, with a disproportionate
conditions of the Creative Commons impact on women and young children whose higher micronutrient needs place them at
Attribution (CC BY) license (https://
higher risk for deficiency [2]. Even prior to the COVID-19 pandemic, micronutrient-rich
creativecommons.org/licenses/by/
diets, including fruits, vegetables, and animal protein, have been out of reach for over
4.0/).

Nutrients 2022, 14, 989. https://doi.org/10.3390/nu14050989 https://www.mdpi.com/journal/nutrients

Nutrients 2022, 14, 989 2 of 13

1.5 billion people due to a cost that exceeds household income [3]. The Green Revolution
that began in the 1960s dramatically enhanced the agricultural productivity of wheat
and rice, reducing hunger and poverty for hundreds of millions of consumers globally.
Yet, it may have also had the unintended consequence of exacerbating micronutrient
malnutrition, due in part to a corresponding decrease in the production of micronutrient-
dense crops, such as legumes, as well as to the milling and polishing of cereal staples that
remove between 20% and 95% of their already low levels of micronutrients [4]. Analysis
of national food supply data indicates that micronutrient availability is inadequate in
several low- and middle-income countries (LMIC) and that the micronutrient density of
the food supply decreased in sub-Saharan Africa from 1961 to 2011 [5]. Further, in South
Asia, time trend data reveal an increase in anemia among women of reproductive age
with increasing production of wheat and rice and lower overall iron density in the diet [4].
Milling, as well as cooking practices, such as boiling rice in excess water, further reduce the
micronutrient content at the point of consumption, particularly for a range of B-vitamins,
zinc, and iron [6,7]. From farm to fork, food systems are not optimized for the delivery of
micronutrients to those most in need.
The health and economic consequences of a food system with low micronutrient
density are significant to both individuals and entire nations. Multiple micronutrients play
a critical role in immune system function and, when deficient, increase susceptibility to dis-
ease [8]. Vitamin A and zinc deficiencies account for a respective 157,000 and 116,000 child
deaths across Africa, Asia, and Latin America each year [9], while dietary iron deficiency
is the seventh leading cause of DALYs (disease-adjusted life years) for children 0–9 years
of age [10]. Micronutrients are critically important to a healthy pregnancy. Deficiency
in micronutrients such as iron, iodine, zinc, folate, and vitamin B12 can increase the risk
of several adverse pregnancy outcomes, including low birth weight, preterm birth, and
neural tube defects. In 17 of the 18 countries with nationally representative data available,
more than 20% of women of reproductive age are deficient in zinc, a micronutrient that is
critical for the optimal growth and development of children [11]. Finally, micronutrient
deficiency, particularly of iron and iodine, has been implicated in GDP (gross domestic
product) losses of between 0.8% and 2% due to their critical role in cognitive development
and work productivity [12].
Increasing the micronutrient density of the food system is a complex endeavor, requir-
ing a range of both demand- and supply-side interventions. On the supply side, biofortified
crops, fortifying staple foods at the point of food processing, and improving both access
and affordability of micronutrient-dense diets have been core intervention strategies, while
demand-side interventions focus on raising consumer awareness of nutrient-dense foods.
While no single intervention will transform the system, food fortification of basic staple
cereals and condiments was ranked by the Copenhagen Consensus in 2008 as one of the
most cost-effective interventions in health and development [13]. In particular, the fortifica-
tion of salt with iodine, at only $0.05 per person per year that generates $30 in economic
return for every $1 invested, remains a cornerstone of food fortification programs [13]. The
objective of this paper is to describe the rationale for expanding the range of micronutrients
carried by salt and salt-containing vehicles, such as bouillon (i.e., multiply-fortified salt
and bouillon). Fortification of table salt and bouillon with multiple micronutrients holds
enormous potential for delivering additional population-wide nutritional and health bene-
fits and is indeed compatible with sodium reduction initiatives to reduce population risks
of non-communicable diseases.

2. Current and Emerging Dietary Trends

Global dietary patterns have undergone drastic changes in the past three decades
as a result of increased urbanization, greater participation of women in the formal work-
force, increased consumption of food away from home, and other factors [14]. The Global
Dietary Database Consortium’s (GDDC) systematic analysis of consumption data from
187 countries revealed that although global consumption of healthier foods and nutrients
Nutrients 2022, 14, 989 3 of 13

(the authors classified the following items as “healthy”: fruits, vegetables, beans and
legumes, nuts and seeds, whole grains, milk, total polyunsaturated fatty acids, fish, plant
omega-3s, and dietary fiber) increased modestly between 1990 and 2010, consumption of
unhealthy foods and nutrients (the authors classified the following items as “unhealthy”:
unprocessed red meats, processed meats, sugar-sweetened beverages, saturated fat, trans
fat, dietary cholesterol, and sodium) increased to a greater extent during the same time
period [15,16]. The analysis also revealed striking geographic and economic disparities.
Improvements in the consumption of healthy foods and reductions in the consumption
of unhealthy foods were greatest in high-income countries, whereas both dietary patterns
worsened in many low-income countries [15]. Notably, middle-income countries exhib-
ited the largest improvement in the consumption of healthy foods but also the largest
deterioration in consumption of unhealthy foods [5]. Similar economic and geographic
differences in food availability and consumption are also evident within countries. For ex-
ample, a recent analysis of foods available within 44 retail outlets across four states in India
revealed increased availability (both in terms of absolute number and relative proportion)
of packaged food in urban vs. rural areas [17]. Unsurprisingly, packaged foods were 50%
less healthy and over three times as expensive as unpackaged food. An understanding of
these geographic and socioeconomic differences in food availability and consumption is
necessary to inform the design and targeting of effective policies and interventions that
will achieve the intended public health outcomes among the most relevant segments of
the population.
At the global level, there is increasing attention to hypertensive disorders and the role
of dietary sodium. Although sodium is an essential nutrient that plays a critical role in
many life-sustaining processes [18], excessive sodium intake is associated with an increased
risk of hypertension and various non-communicable diseases (NCDs) [19,20]. Interestingly,
in 2010, only six of the 187 countries examined by the GDDC met the WHO’s recommen-
dation for sodium intake of <2 g/day (approximately equivalent to <5 g salt per day) [16].
Additionally, more detailed analyses revealed that global mean sodium intake in 2010 was
3.95 g/day (10.06 g salt per day) and had not changed significantly since 1990 [21]. Asian
regions tended to have the highest salt intakes, whereas countries in sub-Saharan Africa,
Latin America and the Caribbean, and Oceania tended to have lower estimated intakes in
relative terms, although there was more uncertainty in these lower estimates. Globally, salt
intake increased from 4 g to 5.6 g per capita per day from 2010 to 2017 [22].

3. The Role of Salt and Bouillon in Food Systems Transformation

Improving the nutritional quality of the food supply through increased micronutrient
density of foods was identified as a candidate double-duty action to address multiple forms
of malnutrition [23]. Food fortification is, therefore, an integral part of food systems change
and can be considered a double-duty intervention as long as the program is designed to
avoid the excessive consumption of micronutrients or of the fortification vehicles them-
selves. Multiply-fortified salt and bouillon are especially well suited to the need, given
their primary role as flavor enhancers for foods that are cooked at home. Building on a
successful history of salt iodization, both salt and bouillon are increasingly considered
fortification vehicles for a range of other micronutrients [24–26]. These condiments are
uniquely suited to meet the criteria set out by the WHO in the 2006 food fortification
guidelines [27]: they tend to be centrally processed, are consumed by a large proportion of
the population in consistent quantities, and can be fortified with available micronutrient
fortificants (though additional research is underway to address issues such as micronutrient
stability [28] and bioavailability [29,30]). Salt and bouillon (where commonly used) are
universally consumed across all income classes [31–33]. A survey of fortifiable food use
in four African countries found that salt was most commonly available in households;
samples of fortifiable (industrially processed) salt were collected from 72–86% of house-
holds compared with <32% for wheat and maize flour [32]. In a second analysis from West
Africa, bouillon was consumed by 79–99% of women in the past week, and the average
Nutrients 2022, 14, 989 4 of 13

frequency of consumption was 5–7 days per week [33]. While some differences in bouillon
consumption were observed between urban and rural strata in Burkina Faso and Niger, the
reach of bouillon remained high (>~50%) in all strata, and in other countries, there were no
differences in reach by residence (98% vs. 100% in Senegal; 93% vs. 97% in Cameroon) [33].
Modeling studies have demonstrated the potential for the fortification of salt and
bouillon to fill dietary micronutrient gaps. In some contexts, these condiments may be con-
sumed within a narrower range of intakes compared to other potentially fortifiable foods,
which facilitates the selection of fortification levels that balance micronutrient inadequacy
and excess. Modeling of national dietary intake data (collected by 24-h dietary recall) from
Cameroon showed that the distribution of bouillon intake was less skewed than the distri-
bution of wheat flour intake and that bouillon fortification with vitamin A and folic acid
could achieve similar reductions in inadequate intake, with a lower likelihood of exceeding
the tolerable upper intake level (UL) compared to wheat flour fortification [34,35]. Figure 1
provides a visual depiction of these benefits, with almost zero percent of the population
at risk of exceeding the UL for both vitamin A and folic acid at the modeled fortification
levels for bouillon. In yet another modeling study that utilized national household survey
data from Cameroon, Ghana, and Haiti, bouillon fortification with micronutrients was pre-
dicted to reduce the prevalence of inadequate intakes among women, men, and preschool
children by 15–33 percentage points (pp) for vitamin A (120 µg retinol/g), 11–33 pp for
folate (80 µg folic acid/g), 12–67 pp for vitamin B12 (1.2 µg/g), 5–12 pp for iron (5 mg/g,
assuming 2% absorption), and 14–42 pp for zinc (3 mg/g), suggesting that the reach and
amount of bouillon consumed in these populations is sufficient to achieve a public health
impact across multiple micronutrients [36]. Likewise, modeling of detailed dietary intake
data has also been used to inform fortification levels for research on multiply-fortified salt
to select levels that best balance efficacy and safety (CM, personal communication).
Salt and bouillon, therefore, hold high potential for reducing the health burden from
micronutrient deficiencies, particularly in countries where the industries are moderately
consolidated. Iodized salt has already demonstrated this potential at scale, with a signifi-
cant impact on goiter reduction and improved IQ since its introduction almost a century
ago [37,38]. A growing evidence base for the dual fortification of salt with iodine and
iron indicates positive impacts on hemoglobin, iron status, anemia, and iron deficiency
anemia [39]. While a variety of interventions exist to deliver specific nutrients (including
the delivery of supplements or promotion of specific nutrient-dense foods), large-scale
food fortification tends to be cost-effective relative to other micronutrient-specific inter-
ventions [40] and relative to other programs to improve maternal and child nutrition and
health [41].
Given the ubiquitous consumption of salt and bouillon and the opportunity for enor-
mous health impacts, fortifying these vehicles with multiple micronutrients can dramati-
cally change their role within the food system. Rather than being viewed as bad actors, they
can be used as essential vehicles for bridging gaps in the dietary intake of critical micronu-
trients. Concerted efforts to improve nutritional status and related health outcomes through
basic elements of the diet are indeed an important aspect of the food system transformation.
 Nutrients2022,
Nutrients 14, x989
2022,14, FOR PEER REVIEW 5 of 13
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Figure1.1.Distribution
Figure Distributionofof folic
folic acid
acid consumption
consumption fromfrom fortified
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bouillon cube at
cube intake intake
at equivalent fortification levels based on mean national intake, and relative effects
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of each
each vehicle
vehicle on inadequate
on inadequate and excessive
and excessive intakes
intakes amongamong Cameroonian
Cameroonian childrenchildren
1–4 years1–4 yearsFor
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Panels C–F, solid lines indicate prevalence of inadequate intakes, and dotted lines indicate prevalenceprev-
For Panels C–F, solid lines indicate prevalence of inadequate intakes, and dotted lines indicate
alence
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intakes above theabove the Cumulative
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probability distributiondistribution
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wheat flour, at 2.6 mg/kg (designed to provide 70 µg/day based on average national intake of
flour, at 2.6 mg/kg (designed to provide 70 µg/day based on average national intake of 27.0 g/day).
27.0 g/day). (B) Cumulative probability distribution of folic acid intake from bouillon cube, at
(B) Cumulative probability distribution of folic acid intake from bouillon cube, at 70 mg/kg (de-
70 mg/kg (designed to provide 70 µg/day based on average national intake of 1.0 g/day). (C) Preva-
signed to provide 70 µg/day based on average national intake of 1.0 g/day). (C) Prevalence of
lence of inadequate and excessive folate intakes at different levels of fortification of wheat flour. (D)
inadequate and excessive folate intakes at different levels of fortification of wheat flour. (D) Prevalence
Prevalence of inadequate and excessive folate intakes at different levels of fortification of bouillon
of inadequate and excessive folate intakes at different levels of fortification of bouillon cube. (E) Preva-
cube. (E) Prevalence of inadequate and excessive vitamin A intakes at different levels of fortification
lence of inadequate
of wheat flour. (F) and excessiveofvitamin
Prevalence A intakes
inadequate and at differentvitamin
excessive levels ofAfortification
intakes atof wheat flour.
different levels of
(F) Prevalence of inadequate and excessive vitamin A intakes at different levels
fortification of bouillon cube. Reproduced in accordance with a CC-BY Creative Commons Attribu-of fortification of
bouillon cube. This figure is reproduced from Engle-Stone et al. [34] under a Creative
tion license (citation: Reina Engle-Stone, Stephen A. Vosti, Hanqi Luo, Justin Kagin, Ann Tarini, Commons
attribution
Katherine license.
P. Adams, Caitlin French, Kenneth H. Brown. Weighing the risks of high intakes of se-
lected micronutrients compared with the risks of deficiencies. Annals of the New York Academy of
Sciences. 2019; 1446(1): 81-101. doi:10.1111/nyas.14128).
Nutrients 2022, 14, 989 6 of 13

4. Salt and Bouillon Fortification within the Global Effort to Reduce Dietary
Sodium Intake
Salt and bouillon contain high sodium levels of approximately 40% and 20–30%,
respectively. As outlined above, global consumption of sodium is above recommended
levels, and the average daily intake is continuing to increase [21,22,42]. Ironically, countries
that are well suited for multiply-fortified salt and bouillon to address gaps in micronutrient
intake are also the regions with the highest prevalence of hypertension, in particular LMICs
in sub-Saharan Africa and South Asia [43–45]. Further compounding the high incidence
is the lower awareness of hypertension and treatment resulting in greater cardiovascular
disease (CVD) severity and secondary complications in these LMIC regions compared with
high- and middle-income countries [43,46].
Sodium reduction has been identified as a cost-effective mechanism to reduce hy-
pertension, CVD, and NCD mortality across all economic levels, including in LMICs [47].
Ideally, sodium reduction strategies should be developed in accordance with distinct di-
etary patterns. The dietary source of sodium can vary drastically according to geography
and income. There are three main sources of sodium in the diet: (1) sodium naturally
present in food, (2) sodium added to packaged or processed foods, and (3) sodium added
during cooking or prior to eating at the table (discretionary/table salt). In high-income
countries, the vast majority of sodium is consumed from processed foods; however, in
lower-income countries, most sodium comes from salt (or seasoning such as bouillon) that
is added during cooking (i.e., discretionary salt) [48]. Thus, attempts to reduce sodium
levels in discretionary salt and bouillon consumed in LMICs hold strong potential for
reducing sodium intake and, in turn, making progress toward the WHO’s 2030 goal of
reducing premature deaths from NCDs by 25% [49].
A recent analysis of discretionary salt intake in 33 studies revealed an inverse corre-
lation between a country’s GDP per capita and the proportion of daily salt intake from
discretionary salt. For every $10,000 GDP per capita, the proportion of daily salt obtained
from discretionary sources was lower by 8.7% [42]. Therefore, the amount and source of
salt consumed by different segments of the population, as well as the various purchasing
and/or procurement modalities, have important implications for the design of sodium
reduction and fortification efforts alike.
While LMICs have the highest rates of hypertension and mortality due to CVD com-
pared with high- and middle-income countries, there are fewer salt reduction initiatives in
these geographies [50]. Interventions for population-wide sodium reduction include con-
sumer education to reduce intake of high salt foods (e.g., media campaigns or front of pack
labeling), reformulation of foods to contain lower sodium content [48], and government-
led initiatives to set voluntary targets or mandatory maximum levels [47,50,51]. Options
for reducing sodium intake from discretionary use of salt and bouillon in home cooking
include consumer education to reduce the addition of salt to foods while cooking in the
home environment [52] and increasing the use of salt substitutes [53].
With the global effort to reduce salt intake to tackle rising NCD incidence, there
is concern that this trend is incompatible with the utilization of salt as a fortification
vehicle. Reducing salt intake could: (i) lower the effectiveness of salt fortification programs,
resulting in an increased incidence of micronutrient deficiency, particularly iodine at
present [54,55] and/or (ii) reduce the effectiveness of salt and salt-containing condiments
for additional micronutrients beyond iodine [56]. Additionally, fortified salt or bouillon
may be seen to have greater health benefits by a consumer (e.g., positive consumer bias
toward foods with front of pack nutrient claims [57]) encouraging increased consumption
and a higher intake of salt [58]; however, there is no clear evidence to support the concern
that fortification leads to higher consumption of the vehicle.
The public health goals of reducing salt intake while fortifying salt to increase mi-
cronutrient intake (e.g., through salt iodization) are indeed compatible, given that the
concentration of micronutrients can be adjusted as the intake of salt/bouillon is reduced
(further referred to in the paper as titration) [54,59]. Success will require continuous moni-
Nutrients 2022, 14, 989 7 of 13

toring of salt intake (e.g., through 24-h urinary sodium measures and dietary intake surveys)
and the level of micronutrient intake (e.g., comprehensive dietary assessments to under-
stand the contribution of iodine from fortified or other dietary sources) to enable titration
of the fortificants in salt to the level required (i.e., to reduce the prevalence of inadequate
micronutrient intake to the greatest extent possible while minimizing the proportion of the
population with intake above the tolerable upper intake level) [55,60]. While there appears
to be significant consensus on the compatibility of micronutrient fortification and sodium
reduction initiatives [54,58,59,61,62], there are few reported examples in practice, likely
due to few countries successfully reducing sodium intake [22]. One reported example
is Switzerland, where voluntary iodine levels in salt have been increased in response to
successful salt reduction to ensure longer-term adequate intake of iodine [63].
While policies for fortification and reduction of salt intake are compatible, the impact
of salt reduction would be specific to the context and country [59]. Key factors affecting
strategies to titrate fortification levels over time would include the amount and source of
salt reduction across the population (i.e., sodium reduction in the household during cooking
vs. from processed foods) and changes in the dietary pattern of the population, including
through improved nutritional quality of the diet or availability of new fortified foods.
Further, given the close synergy between these two public health strategies, it is important
that there is (i) better coordination at the country level across both fortification and sodium
reduction programs/policies and (ii) increased communication and messages developed to
reinforce their complementarity. For example, in Italy, a previous communication strategy
was “Little salt, but all iodized” [59]. Such communication strategies may overcome
concerns about the increased consumption of salt due to the perceived health benefits from
fortification. These campaigns should ideally communicate both the positive health effects
of iodized salt and the negative health effects of excessive salt intake to support the behavior
change. In fact, another study in Italy found significant improvements in children’s intake
of iodine through salt but little change in the intake of high-sodium processed foods after an
educational campaign that addressed both [64]. The authors hypothesized that this might
be because the children were educated on the benefits of iodine, but the campaign focused
less on the link between excess sodium intake and cardiovascular disease. Efforts targeting
the availability and accessibility of processed foods high in sodium vs. lower-sodium
alternatives may also be needed.

5. Areas of Further Research Needed

Several areas of innovation are required to meet the dual goal of broadening the mi-
cronutrients added to salt and bouillon while also meeting salt reduction targets in LMICs.
These include the development of low-cost sodium substitutes, micronutrient innovations
to ensure sensory, cost, and stability attributes can be met, and dietary surveillance to
support the continued optimization of food fortification programs. These types of inno-
vations are critical for maximizing the potential role of salt and bouillon within the food
systems transformation effort. Low-cost sodium substitutes would allow governments to
leverage a broader range of salt-containing condiments as vehicles of essential micronu-
trients. Micronutrient innovations would improve the technical and economic feasibility
of doing so, and new surveillance tools would enable critical adjustments to the range
and levels of micronutrients needed in the population as dietary patterns and intervention
programs evolve.

5.1. Sodium Substitutes

A key challenge for sodium reduction is the loss of taste when salt is removed, com-
bined with the fact there is currently no direct salt substitute available. Partial substitution
with other non-sodium salts is an option that is widely used in many foods (e.g., potas-
sium chloride or ammonia); however, these have negative sensory effects when used at
higher concentrations. Due to the selective nature of the ion channel(s) associated with the
detection of salt taste, there may not be a true substitute that can replace salt [48]. Optimal
Nutrients 2022, 14, 989 8 of 13

methods for sodium reduction in current/future micronutrient vehicles containing high salt
levels such as bouillon and other condiments require further research. Thus, salt reduction
of high-sodium-containing foods such as condiments and bouillon will likely involve mul-
tiple strategies for reformulation to enable significant reduction [48]. In the case of bouillon,
additional options include reformulating to exploit cross-modal interactions (taste-taste or
taste-aroma) to enhance saltiness and overall flavor while reducing the salt content. In such
a way, there is the potential to maintain overall flavor intensity and consumer satisfaction
while enabling a reduction in salt levels.
Salt also delivers other techno-functional properties beyond making food taste appet-
itive. For example, salt contributes to the size and compression of a bouillon cube, and
salt reduction will require a filler to maintain the cube size and compression. Further,
salt is a low-cost ingredient, and reformulation to reduce salt and/or replacement with
other ingredients to account for the loss of flavor or other techno-functional properties
will have added costs above the cost saving from the salt removed. This increased cost
will likely be passed onto the consumer, which could impact its affordability and thereby
reduce the frequency and amount consumed across a population. While it is possible to
titrate fortification levels higher if consumption decreases, it will be important to ensure
cost increases due to sodium reduction and fortification do not reduce consumption by
the lowest socioeconomic groups that are likely to gain the greatest benefit from fortified
foods/programs.

5.2. Micronutrient Innovation

Expanding the micronutrients in salt and bouillon beyond iodine holds great potential
for reducing a range of deficiencies in a single product, yet such products can introduce
both stability and sensory challenges. Iron alone in various double-fortified salt (DFS)
formulations, in which an iron-containing premix is added to salt, have revealed an unac-
ceptable sensory profile, including dark specks that are particularly acute in poor-quality
premix (in which the encapsulation does not fully cover the dark iron) or when the premix
is added to poor-quality salt (in which the moisture can erode the encapsulation) [65].
Further, when the iron encapsulation dissolves with heat during cooking, it darkens the
food and can affect consumer acceptance [66]. Iron can also destabilize iodine [67]. Re-
search efforts are currently underway to address these challenges using a whiter and less
reactive form of iron, such as ferric pyrophosphate, with added enhancers to compensate
for its lower bioavailability [30,68]. While a promising iron compound for the fortification
of double and multiply-fortified salt, competitive approaches could further optimize the
bioavailability, sensory impact, and combinability of iron with other micronutrients in salt
and salt-containing vehicles.
Vitamin A stability is also a challenge, particularly when stored for long periods of
time near other micronutrients and then exposed to high temperatures, such as in multiply-
fortified bouillon. Commercially available forms of encapsulated vitamin A have limited
stability in such conditions, requiring significant overages to ensure that target delivery
levels are available at the time of consumption. Several research efforts are underway to
strengthen vitamin A encapsulation with both natural and synthetic polymers [69]. These
polymers are pH-sensitive, protecting vitamin A through the cooking process and releasing
at low pH in the stomach to enable absorption in the proximal duodenum. However, these
technologies have yet to be commercialized.
Finally, in some geographies, such as Ethiopia, where neural tube defects are of great
public health concern, variants of double-fortified salt with iodine and folic acid are now
in development. When added to the iodine overspray, folic acid can turn the salt a pale
yellow. Consumer acceptability still needs to be assessed. If unacceptable, new methods of
integrating folic acid into salt, such as the development of a concentrated folic acid premix
that is then blended into salt, will need to be developed.
Nutrients 2022, 14, 989 9 of 13

5.3. Dietary Surveillance

To ensure national fortification programs are operating as efficiently and effectively as
possible, policies should be reviewed and modified on a regular basis to account for possible
changes in the prevalence of micronutrient deficiency, consumption of the vehicle, and/or
other dietary sources of micronutrients. This process requires up-to-date information
on dietary intake, coverage and quality of the fortified vehicle, and the status of other
micronutrient interventions. Unfortunately, many of the current data collection methods
that provide high-quality information on individual food and nutrient intake (such as
observed, weighed food records) are expensive, time-consuming, and labor-intensive.
Innovations to develop and apply assessment tools that are more field-friendly may increase
availability of the information needed to adjust fortification programs. For example, tablet-
based programs have been developed to facilitate the collection of dietary intake data [70],
and new statistical tools can decrease the time and cost of data analysis [71]. Where there
are questions related to the coverage and contribution of other fortification programs,
targeted assessments such as the Fortification Assessment Coverage Tool may suffice [72].
In addition, point-of-care biomarker tests merit exploration as a source of information on
changes in population micronutrient status. Other possibilities include exploring ways
in which secondary data sources can be effectively utilized, such as information collected
at the retail level, or through national household surveys, such as Household Income
and Expenditures Surveys, that collect information on household food acquisition or
consumption [73]. While efforts to address micronutrient deficiencies and chronic disease
are often managed by separate organizations, collaboration between these groups may
facilitate the joint collection of information that can inform multiple policy objectives; for
example, information on salt consumption and/or urinary sodium excretion could be used
to inform programs to fortify salt as well as sodium reduction strategies. In addition to
efforts to streamline the collection and analysis of these data, clear pathways must be in
place for making this information available in relevant policy discussions.

6. Summary
Our global food system lacks the critically needed micronutrients to meet the daily
requirements of the most at-risk populations. Due to the phenomenal success of salt
iodization over the last 30 years, we would be remiss not to consider expanding the range of
micronutrients in salt as a means of supporting the transformation of the food system. The
factors that have made salt iodization so successful, including its universal consumption
and narrow range of consumption across the population, are even more relevant today, as
standards authorities grow increasingly concerned with the risks of excessive intake and
potential toxicity as multiple micronutrient interventions are deployed. To maximize the
effectiveness of fortification programs, the policy focus for adding micronutrients should be
on discretionary salt rather than on salt contained within processed foods, as sodium intake
comes largely from the salt used during cooking and at the table for those populations with
the highest gaps in intake.
On the surface, the strategy to fortify salt with multiple micronutrients might seem
incompatible with guidelines from global and local health authorities to reduce salt intake to
reduce the risk of hypertension and other NCDs. While there is concern that micronutrients
can lead to the increased intake of salt, in truth, there is no evidence that iodization has
increased levels of salt consumption. Additionally, fortification is a flexible strategy, as the
concentration of micronutrients in salt can be adjusted over time to meet population intake
targets as salt consumption levels decline in response to sodium reduction initiatives, as
has been demonstrated in Switzerland. However, there are several areas of research and
innovation that could better support the deployment of these twin strategies, including the
development of cost-effective salt substitutes and micronutrient innovation to ensure that
sensory, bioavailability, and stability targets can be maintained as micronutrients beyond
iodine are added to salt, potentially at increasingly higher concentrations over time as salt
reduction programs take effect. Finally, new methods for cost-effectively capturing salt
Nutrients 2022, 14, 989 10 of 13

intake in the population are required for understanding changing population intakes and
maximizing the impact of a combined salt fortification and NCD reduction strategy. While
fortification of salt and salt-containing condiments is not a panacea, it holds enormous
potential for being a critical anchor for meeting the dietary requirements across a broad
range of micronutrients for those with the greatest need, as we collectively move toward a
food system that delivers better health for all.

Author Contributions: Conceptualization, D.M., C.M.M., N.A. and R.E.-S.; writing—original draft
preparation, D.M., C.M.M., N.A. and R.E.-S.; writing—review and editing, D.M., C.M.M., N.A.
and R.E.-S.; visualization, R.E.-S. All authors have read and agreed to the published version of
the manuscript.
Funding: This research was funded by the Bill and Melinda Gates Foundation: DM is a staff member
and grants to: CMM/UCSF INV-002945, NA/CSIRO INV-002988, and RES/HKI/UCD INV-007916.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.

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