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Millers essential
to public health
success story
Fortifying flour is a great public
health success story. Millers add
vitamins and minerals to their
products, and consumers increase
their nutrient intake while eating
foods they enjoy. In turn, the
population greatly reduces its
risk of debilitating anemia from
nutritional deficiencies and devas
tating birth defects from insufficient
folic acid.
F
for other nutrients that were included in the premix. The iron
spot test is formally Method 40-40.01: Iron Qualitative Method
as approved by the American Association of Cereal Chemists
(AACC).
The spot test works well for ferrous sulfate, ferrous fumarate, and
electrolytic iron. When flour is fortified with sodium iron EDTA
(NaFeEDTA), the test works when hydrogen peroxide is not used
as a reagent.
Outside Testing: Periodically send fortified flour samples to
laboratories to be sure that all the specified nutrients are present
in the correct amounts. This requires sophisticated equipment and
careful adherence to protocols because the level of vitamins and
minerals is very small compared to the volume of flour. Some
milling associations or large milling companies have centralized
laboratories for this work.
Keeping accurate records of these procedures will be useful
when regulatory authorities audit the mill for compliance with
the national fortification standard. More importantly for public
health, these steps will give millers confidence that they are
investing in the well-being of their families, their staff, and their
customers.
Wheat and maize flours are commonly fortified with iron to
prevent anemia from iron deficiency. When asked what it felt
like to have anemia, people compared it to walking in quicksand
and having constant jet lag. In addition, iron deficiency limits
a childs cognitive development which affects future earning
potential, and it contributes to 20% of all maternal deaths.
Anemia from iron deficiency is not confined to lower-income
countries. Iron deficiency is the most common and widespread
nutritional disorder in the world, according to WHO. WHO
estimates that 42% of anemia in children, 49% of anemia
in non-pregnant women of child-bearing age, and 50% of
Iron spot test - The red dots in the flour sample indicate that the
flour has been fortified with iron, and that is considered a proxy
for the other nutrients that were in the premix.
Photo courtesy of FFI.
folic acid to reduce the risk of neural tube defects (NTDs). These
birth defects include spina bifida which causes permanent loss of
sensation and varying degrees of paralysis. Another NTD called
anencephaly is the result of a malformed brain, and it is always
fatal. A rare NTD is encephalocele in which part of the brain
protrudes through the skull.
The neural tube forms within the first few weeks after
conception, and women may not realize they are pregnant during
this time. If they wait until the pregnancy is confirmed to take
folic acid supplements, it may be too late for folic acid to have
its protective effect. Adding folic acid to flour, on the other hand,
helps ensure that women have enough folic acid as they enter the
pregnancy and throughout the critical first few weeks.
Every country that studied its birth defect prevalence showed a
decline in NTDs after fortification. One analysis showed that the
average drop in NTD birth prevalence after fortification was 46%.
The most recent example is from Brazil which recorded a 30%
decline in NTDs after fortification.
Another benefit to preventing NTDs is healthcare savings.
People with spina bifida can lead productive lives, but they may
need a lifetime of surgeries and treatments. Some countries have
compared the cost of fortification with healthcare expenditures
averted when spina bifida is prevented. The cost:benefit ratios
reported were 1:12 in Chile and 1:30 in South Africa. A recent
study in the United States showed that the cost savings were US$
603 million more than the cost of fortification.
Currently 79 countries have national mandates that require
fortifying wheat flour, maize flour, and/or rice with folic acid.
Yet less than 30% of the worlds industrially milled wheat flour
is fortified, according to FFI. About 48% of industrially milled
maize flour is fortified, but the proportion of maize flour that is
industrially milled is low. Less than 1% of industrially milled rice
is fortified.
In addition to the actions listed above for internal quality
control, millers can take several steps to make progress with
flour fortification. First, if your country already has legislation to
fortify flour, compare the standard with WHO recommendations
which are available in six languages.
See table one for recommended levels of five nutrients based
on the amount of wheat flour that is available for human
consumption. Notice that the iron and zinc recommendations are
different for high and low extraction flours. The estimates are
also based on grain availability. Those estimates from the Food
and Agriculture Organization of the United Nations are on the
country profiles on the FFI website.
Countries may want to include nutrients that are not in
the WHO recommendations in their fortifition standards.
For example, many countries include the B vitamins niacin,
riboflavin, and thiamin in flour fortification. On the other hand,
many countries do not include vitamin A in flour fortification
even though it is included in the WHO recommendations
because they fortify adequately fortify cooking oil or sugar with
vitamin A. Contact FFI at info@ffinetwork.org for assistance in
developing an appropriate flour fortification standard.
If your country does not have a fortification mandate, participate in
a National Fortification Alliance to promote fortification. Information
from the milling industry will help ensure that a country develops
standards that are feasible to implement. Contact FFI at info@
ffinetwork.org to find out if your country has a National Fortification
Alliance or other group advocating for fortification.
For more information on internal quality control and fortifying
flour to prevent nutritional anemia and neural tube birth defects,
see the FFI website.
www.ffinetwork.org