Better health through flour fortification

by Teresa Acklin
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The addition of nutrients to flour is gaining momentum around the world.

   No other technology in the world today offers as large an opportunity to improve lives and accelerate development at such low cost and in such a short time.” That ringing endorsement comes from the World Bank and a host of other international organizations in encouraging the adoption of micronutrient fortification programs around the world, particularly in developing countries.

   The fortification of wheat flour has been embraced for so long in the United States and other parts of the developed world that it draws little attention, even in product labeling and promotion activity. And efforts to persuade developing countries to adopt fortification programs are not new, by any means.

   But the endeavor — particularly for the addition of iron to wheat flour — appears to be gaining momentum as the need, benefits and relative low cost are appreciated by more and more countries. A growing number of organizations, often working in concert, are educating governments and food industries around the world to encourage fortification of flour. Those efforts extend from Mexico to Moscow.

   The World Bank, in a 1994 report, “Enriching Lives,” concluded that “millions of lives around the world would be saved and the quality of life of hundreds of millions would be markedly improved — all very inexpensively — by eradicating three vitamin and mineral deficiencies in people's diet.” Noting that the 1990 Summit for Children adopted the goals of eliminating iodine and vitamin A deficiencies by the year 2000 and of reducing iron deficiency anemia in women by one-third, the World Bank report said, “The goals are achievable only if political will, state-of-the-art technology and private, public, and international resources are marshaled for the effort.”

   The goals were reaffirmed in several later international meetings, including the 1992 International Conference on Nutrition in Rome.

   According to the World Health Organization, more than 2.8 billion people around the world are affected by vitamin A, iodine or iron deficiencies. Iron deficiency is the most common, with an estimated 2.15 billion people judged iron-deficient or anemic. That total includes 206 million in Africa, 94 million in the Americas, 149 million in Southeast Asia, 27 million in Europe, 616 million in the Eastern Mediterranean and 1,058 million in the Western Pacific region.

   “These micronutrient deficiencies are among the 10 most burdensome diseases in the world,” the World Bank has noted. “Poor people are more likely than others to suffer from micronutrient malnutrition. Thus, the developing world, where most of the world's poor live, suffers most from these deficiencies. These deficiencies existed in the developed countries at the turn of this century but have now largely been eradicated, although some countries in Europe still do not iodize their salt or fortify their food.”

   Food fortification and dietary diversification are the highest priorities for the World Bank. The organization has identified food fortification as very promising for many countries where a staple food is processed commercially, for example, wheat and maize flour, sugar, salt and oils.

   Claudia Rokx, a nutrition consultant in the Human Development Department at the World Bank, said the Bank's fortification programs in developing countries were focusing primarily on iron.

   A common thread in the experiences of the various groups promoting micronutrient fortification is that the key constraints to achieving success include a lack of awareness and commitment of policy makers and consumers and a lack of enforcement of industry compliance with fortification laws. Indeed, a compilation of fortification practices in 23 countries by The Micronutrient Initiative (see page 18) shows that not all countries with fortification regulations on the books actually engage in the practice, even though the economic and social payoffs from micronutrient programs reach as high as 84 times the program costs.

   “The problem in Latin America is not as much legislation, as many countries already have legislation, but implementing and monitoring it,” a recent World Bank summary noted. “Legislation should be joined by financial and political inducements to industry. Some of the incentives used in effective fortification programs have been tax relief, import licenses, loans for equipment, subsidies on fortificants and positive press coverage.”

   Industry cooperation is vital, and officials at the World Bank have praised the involvement of the Asociacion Latino-americano de los Industriales Molineros (ALIM, the Latin American Millers Association) in helping promote iron fortification in Latin America. The World Bank is examining the possibility of pursuing grant money to use as funds to help encourage ALIM's continued involvement as well as technical assistance for individual governments to improve their legislation and monitoring systems.

A Multi-Sectoral Endeavor

   One of the most comprehensive situation reports on enrichment of flour, both wheat and maize, is provided in an ongoing project of The Micronutrient Initiative at Ottawa, Canada.

   The Micronutrient Initiative was established in 1992 as an international secretariat within the International Development Research Center in Canada by several sponsors: the Canadian International Development Agency, the United Nations Children's Fund (UNICEF), the United Nations Development Programme and the World Bank.

   While addressing all available approaches in correcting micronutrient deficiencies, the focus of The Micronutrient Initiative is on sustainable interventions, including the promotion of breast feeding and dietary modification, with fortification of commonly eaten foods as the centerpiece of efforts for the medium term.

   “Food fortification,” according to T.M.I., “is a multi-sectoral endeavor, calling for collaboration between national governments, private industry, consumer groups, international organizations and international expert groups.”

   The first draft of the T.M.I. situation report, issued last October, describes the status of the enrichment process in 23 countries of Latin America and the Caribbean and reviews major characteristics of the milling industry in each country.

   The Micronutrient Initiative report shows wide variations in wheat and maize flour production, consumption and fortification practices among the 23 countries.

   Median consumption of wheat flour in 1995 was 88 grams per person per day, with a maximum consumption of 384 grams per person per day (Chile), the report said. In the countries for which information was received for both years, the median wheat consumption showed a tendency to increase, rising from 90 grams in 1990 to 99 grams in 1995.

   Less information was reported for the consumption of maize flour, the T.M.I. report said. “Minimum consumption was 9.7 grams per person per day (Panama) and maximum consumption was 95.2 grams (Venezuela),” the report said. “Average consumption for all of the countries that provided information was 56.5 grams per person per day.”

   The T.M.I. report also summarized policies on enrichment of wheat flour in the Latin American/Caribbean countries. In 15 countries (78.9%), nutritional enrichment of cereal flours is included in the legal code. Of the four remaining countries, two (Colombia and Ecuador) are in the process of approving the law that allows enrichment, and two (Cuba and Haiti) do not have laws referring to the enrichment of cereal flours.

   Of the 15 countries whose legislation includes enrichment of flour, eight require the procedure as obligatory. In the other seven, nutritional enrichment is defined only with suggested implementation levels, according to the diverse classes of flour offered to the consumer. In 12 of the 19 countries reporting (63%), nutritional enrichment of flours is already being implemented, and in the remaining three, implementation is in the process of approval.

   The target concentration of iron defined in most of the countries indicates that enrichment is being implemented in “restoration” mode, the T.M.I. report said. That term describes enrichment at levels necessary to compensate the loss of iron and other micronutrients that occurs during the milling process.

   In five countries — El Salvador, Bolivia, Guatemala, Venezuela and Peru — the levels required by the regulations approved (or in process of approval) are higher. All of the countries that reported enrichment programs indicated that the process is carried out at the mill level, according to the T.M.I. report.

   The Micronutrient Initiative joined with the International Agricultural Centre in Wageningen, The Netherlands, last year in issuing a 110-page reference publication, “Micronutrient Fortification of Foods ... Current Practices, Research and Opportunities.” The volume, whose authors include Mahshid Lotfi and M.G. Venkatesh Mannar of The Micronutrient Initiative, was prepared “as a useful reference for national micronutrient program managers and food industry managers to plan and expand food fortification as a long-term and sustainable solution to the global problem of micronutrient malnutrition.”

   The Micronutrient Initiative also is preparing a comprehensive technical manual on flour fortification as an educational and operational tool for flour millers around the world. The manual, which is now in the preliminary draft stage, will include chapters on selection of fortificants, stability and bioavailability; equipment needs, installation, maintenance and costs; planning and implementation of national programs on flour fortification; regulatory guidelines; and monitoring programs.

Widespread Interest

   Indicative of the widespread interest in fortifying wheat flour is the consensus statement adopted by participants at a joint strategy development workshop on food fortification held last October in Muscat, Oman.

   “The fortification of wheat flour with iron in particular has the potential to make an important contribution to reducing the problem of anemia in women and children throughout the Eastern Mediterranean, North Africa and the Middle East,” according to the consensus statement. The group also issued recommendations on the nutrients and the levels to be added (see table on page 21).

   The workshop was sponsored by the World Health Organization, UNICEF, The Micronutrient Initiative and the Program Against Micronutrient Malnutrition, which is based at Emory University in Atlanta, Georgia, U.S. Attending the workshop were representatives from the ministries of health, milling industries, and other government agencies from 11 countries.

   Wheat flour is being fortified with iron in Saudi Arabia and in parts of Egypt and Iran, according to the workshop group. Wheat flour has been fortified with iron in the past in Oman and Bahrain, and will shortly be re-introduced in these countries, while other countries will start to develop plans for the introduction of iron fortification of wheat flour.

   Among the recommendations adopted by the workshop group were the following:

   In the context of bilateral or multilateral food aid, governments should insist on receiving only enriched food commodities that meet their national standards;

   governments should regulate both the manufacture and the importation of food products that have been identified to require fortification;

   mechanisms for assuring the quality of fortification and enforcing regulations should be developed at the start of the program; and

   further development work is needed on ways that small wheat mills (those producing less than 100 tonnes per day) can fortify their flour.

   The group concluded that in most countries involved, the prevalence of anemia in women and children was reported to be moderate or severe.

   “Wheat flour is the main staple food in the region,” the group said. “Fortification of wheat flour in most countries in the region will be simple and cheap and will be a major strategy to prevent anemia in the region.”

Status of iron fortification in Latin America and the Caribbean

ArgentinaYesNoIn process
BoliviaYesNoIn process
ColombiaNoStandard In process
being defined
Costa RicaYesYesYes
Republic(maize flour)
EcuadorNoStandardIn process
being defined
El SalvadorYesYesYes
NicaraguaNoStandardIn process
being defined
& Tobago
(pre-cooked maize
flour and wheat flour)
* Standard proposed and under study for future approval.
Source: The Micronutrient Initiative

Flour fortification recommendations

At the October 1996 strategy development workshop on food fortification, Muscat, Oman, the group agreed on flour fortification and issued several recommendations.
1. Recommended addition levels to flour
Ferrous sulfate30 parts per million
Folic acid 1.5 ppm
Reduced iron60 ppm
Folic acid 1.5 ppm
2. Quality assurance
A quality assurance system should be implemented to record data,
monitor addition rates and evaluate results.
3. Additive specifications
Specifications to consider when purchasing additives include:
• particle size and color
• chemical content
• bulk density
• dosage/metering
• packaging
• storage, shelf life, special handling requirements
• climatic reactions — stability and flowability
• flour/baking — effects on shelf life, storage
• technical service and support for product