flour fortification
This is the first article in a two-part series on flour fortification. This article focuses on the health implications of fortification while the second article, which appeared in the June issue of World Grain, will look at how the Food Fortification Initiative is spreading throughout the world.

According to the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC), iron deficiency anemia is the most widespread nutritional deficiency in the world and has important consequences for child development and enormous economic costs.

Likewise, the CDC, WHO and International Clearinghouse for Birth Defects Surveillance and Research (ICBDSR) have found that neural tube defects are among the most common structural congenital anomalies worldwide, with an estimated 300,000 cases per year. They contribute to 10% of deaths during the first 28 days of life.

Obviously, the best way of preventing micronutrient malnutrition is to ensure consumption of a balanced diet that is adequate in every nutrient. Unfortunately, this is not achievable everywhere since it requires universal access to adequate food and appropriate dietary habits.

From this standpoint, food fortification has the dual advantage of being able to deliver nutrients to large segments of the population without requiring radical changes in food consumption patterns.

The flour milling industry is playing a critical role in combating iron deficiency anemia and neural tube defects with flour fortification, a sustainable and cost-effective approach to preventing these micronutrient deficiencies.

Progress is being made. According to the Food Fortification Initiative (formerly known as the Flour Fortification Initiative), 87 countries have legislation to mandate fortification of at least one industrially milled grain. Of these, 86 countries fortify wheat flour alone or in combination with other grains.

Iron deficiency Anemia, neural tube defects

Anemia is defined by a decrease in the total amount of hemoglobin or the number of red blood cells. Iron deficiency anemia is a form of anemia due to the lack of sufficient iron to form normal red blood cells and typically caused by inadequate intake of iron, chronic blood loss, or a combination of both.

Worldwide, iron deficiency anemia is the most common and widespread micronutrient malnutrition, and is a public health problem in both industrialized and non-industrialized countries that affects more than 24% of the world’s population, but even more so in developing regions. It can reach all age groups, although young children and women tend to be among those most at risk of developing micronutrient deficiencies. Iron deficiency impairs the cognitive development of children from infancy through to adolescence and also damages immune mechanisms, and is associated with increased morbidity rates. It also may have adverse impacts on social and economic development and in different areas, according to the local conditions.

WHO estimates that 114.7 million children, 16.2 million pregnant women and 243.2 million non-pregnant women of child-bearing age are globally affected by iron-deficiency anemia.

Birth defects, also known as congenital anomalies, may be defined as structural or functional abnormalities, including metabolic disorders, which occur during embryonic development and can be identified before birth, at birth or later in life. They may be caused by interacting and diverse factors, such as single gene defects, chromosomal disorders, multifactorial inheritance, environmental teratogens or micronutrient deficiencies. In 2012, an estimated 270,358 deaths globally were attributable to congenital anomalies during the first 28 days of life (3.3 deaths per 1,000 live births). Neural tube defects (NTDs) were one of the most serious and most common anomalies. WHO estimates that more than 300,000 newborns worldwide are born with NTDs each year. These birth defects (including anencephaly and spina bifida) occur in the early weeks of pregnancy, often before a woman knows she is pregnant.

Food and Flour Fortification

There always has been confusion between enrichment and fortification terms, and most of the time they are used interchangeably. In the book “Baking Science and Technology, fourth edition,” enrichment is described as the practice of adding back vitamins and minerals lost during processing while fortification is defined as supplementation with nutrients not previously present in the food or not naturally occurring at such high levels. The book also indicated that enrichment describes the addition of the B vitamins and iron to flour because losses in these materials range from 60% to 80% in flours with an extraction rate of 70% to 75%.

WHO/FAO defines food fortification as “the addition of one or more essential nutrients to a food, whether or not it is normally contained in the food, for the purpose of preventing or correcting a demonstrated deficiency of one or more nutrients in the general population or specific population groups.”

This process usually takes place during the processing of staple foods at a central level so that it reaches a considerable proportion of the at-risk populations without requiring their active participation.

||| Next page: Flour fortification as a tool |||

Flour Fortification as a tool

The best way of preventing micronutrient malnutrition is to ensure consumption of a balanced diet that is adequate in every nutrient. However, this strategy is far from being achievable everywhere since it requires universal access to adequate food and appropriate dietary habits. From this standpoint, food fortification has the dual advantage of being able to deliver nutrients to large segments of the population without requiring radical changes in food consumption patterns.

Food fortification is one of the leading public health interventions recommended to prevent and control micronutrient deficiencies. Staple foods and condiments are among the foods most commonly fortified with vitamins and minerals. Wheat flour was the first cereal grain product to be widely fortified, and the first cereal grain recommendations issued by the WHO pertained to maize and wheat flour.

Fortification of industrially processed flour, when appropriately implemented, is an efficient, simple and inexpensive strategy for supplying vitamins and minerals to the diets of large segments of the population.

Boosting iron levels

Adding iron to flour during the milling process helps reduce the risk of iron-deficiency anemia since it is caused by iron deficiency and wheat flour is the staple most commonly fortified with iron in large-scale fortification programs.

FFI compared the change in the prevalence of anemia over time in non-pregnant women in 12 countries with flour fortification and in 20 countries without a flour fortification program present. It found that each year of flour fortification was associated with a statistically significant 2.4% decreased anemia prevalence in women. In comparison, among non-fortification countries, no statistically significant reduction in anemia prevalence was observed over time.

The mandatory fortification of wheat flour with iron significantly furthered the reduction in the prevalence of inadequate intake, except among women of reproductive age, and changed the main contributors to this nutrient in the studied population.

Therefore, monitoring of iron addition in flour is essential to assess compliance to the fortified flour policy and to guarantee a safe iron intake for all the population.

Increasing folic acid

The association between low maternal folate status and increased risk of neural tube defects was first reported over 40 years ago. Adequate periconceptional maternal folate status is critical for embryonic development and prevention of neural tube defects. Clinical trials have established that periconceptional folic acid supplementation prevents the occurrence and recurrence of neural tube defects by up to 70%. Then, the United States Public Health Service recommended that all women capable of becoming pregnant should consume 400 μg of folic acid daily. Since approximately half of all pregnancies in the United States are unplanned, in 1998 the U.S. Food and Drug Administration mandated that folic acid be added to the flour supply to target women of reproductive age and ensure adequate intake of folic acid.

Well-conducted studies from the United States, Canada and Chile have docu­mented decreases of 26%, 42%, and 40%, respectively, in the rate of NTDs affected births after implementation of national regulations mandating wheat flour fortification with folic acid. Wheat and maize flour for­tification with folic acid increases the intake of folate by women and can reduce the risk of neural tube and other birth defects.

A 2015 study found that 35,500 birth defects of the brain and spine were prevented in one year due to flour being fortified with folic acid – that’s an average of 97 healthier babies every day.