Vitamin A Sugar Fortification in Zambia: Opportunities and Challenges

Large‐scale food fortification is a major strategy to improve dietary vitamin A (VA) intakes and control VA deficiency. Zambia introduced mandatory sugar fortification with VA, at a target of 10 mg/kg, in 1998; however, there are conflicting reports as to the program's impact on VA status. Our objective was to assess the current state of the program from the policy level to the household. We conducted key informant interviews with stakeholders regarding the program's history, implementation, impact, and perceived challenges. In one district, we mapped formal and informal sugar vendors and recorded coverage of available brands and packaging options. In a random sample, we conducted a Knowledge, Attitudes, and Practices survey of both vendors and consumers. We obtained 50 g samples of sugar from vendors for quantitative VA analysis using an iCheck portable fluorimeter and, in an ongoing surveillance cohort in this community, collected ~1 g samples for qualitative analysis. Key informant interviews revealed a strong commitment to sugar fortification in Zambia, but also several concerns: potential for excess VA intake, poisoning or infertility, cost of fortificant, and limited resources available for monitoring and evaluation of program impact. Market assessments revealed a variety of sources for fortified sugar. The distribution of VA in sugar in market samples was highly skewed, with a median of 2.4 mg/kg (25 th percentile, 75 th percentile: 1.5, 5.6) and a range from 0.6 mg/kg to 18.0 mg/kg. VA levels in sugar varied by source. Overall, the commitment of stakeholders to VA fortification of sugar is promising for the program's ability to adjust course, as needed, and for its long‐term sustainability. While limited to one area of the country, our data suggest wide variability in VA content, with median levels falling below the 10 mg/kg target. Given observed differences in VA content, it is possible that this is related to varied storage and packaging—a challenge that could be addressed by targeted messages to vendors. Additional research is needed to better understand patterns of sugar consumption at the household level, both to inform the contribution of fortified sugar to overall dietary VA intakes, but also as a baseline in a country that is experiencing a nutrition transition. Support or Funding Information Funded by Sight & Life, with support from CBM Internationa