by Sarah Zimmermann, Communications Coordinator, Food Fortification Initiative


A state in India,plus Afghanistan and Pakistan, led global progress in wheat flour fortification in 2018, according to an annual survey by the Food Fortification Initiative (FFI). In addition, Solomon Islands led progress in rice fortification by passing standards to require fortification of its imported rice.

India's Haryana state began distributing fortified atta (stone-ground, whole-wheat flour) to some of its Public Distribution System beneficiaries in March 2018. The program has expanded and is now benefitting 177,000 people. Haryana leaders plan to scale it up to eventually reach 12.6 million people across the entire state.

Afghanistan and Pakistan fortified less than five percent of their industrially milled wheat flour in 2017, according to the FFI survey. But in 2018, the Global Alliance for Improved Nutrition (GAIN) reported that 73 percent of Afghanistan's industrially milled wheat flour and 51 percent of Pakistan's industrially milled flour was fortified.

In Solomon Islands, all of the domestically produced wheat flour is fortified, but the population consumes more rice than flour-based foods. Consequently,national leaders approved a standard in 2018 to require rice to be fortified with iron, zinc, folic acid, thiamin, and niacin. Requiring fortification of both rice and wheat flour will significantly increase vitamin and mineral intake of the country's nearly 600,000 residents.

In each of these countries, the prevalence of anemia in at least one population group is a 'severe public health problem' - the World Health Organisation(WHO) classification for anemia prevalence higher than 40 percent.

Anemia is a grave concern because:

  • Pregnant women with severe anemia are twice as likely to die during or shortly after pregnancy than non-anemic women
  • Anemic women in low and middle-income countries have a significantly higher risk of having a low-birth-weight infant than non-anemic women. Low birth weight means less than 2500 grams at birth; infants that small are prone to death and diseases while they are young. If they survive, they are more at risk for poor mental development in childhood and chronic health problems such as diabetes and heart disease later in life
  • In childhood, anemia from iron deficiency stunts cognitive development which hinders academic performance and future earnings potential
  • Anemia reduces productivity which may in turn reduce wages. Anemia is estimated to contribute to 17 percent lower productivity in heavy manual labor and five percentlower productivity in other manual labor-based jobs

Deficiencies of iron, riboflavin, folic acid (vitamin B9), zinc, vitamin A, and vitamin B12 can each cause anemia. Fortifying commonly consumed grains with these nutrients can lower the anemia prevalence.

Also, adding folic acid (vitamin B9) to grains has lowered the prevalence of brain and spine birth defects in countries that measure this component of the fortification program. Research published in 2018 credited fortification with preventing 50,270 brain and spine birth defects in one year for an average of 137 healthier babies a day. Yet this is likely only 18 percent of the brain and spine birth defects that could be prevented globally through grain fortification.

Of thefour countries that led progress in 2018, only India has reported birth defect prevalence. Research there shows that 41-to-45 of every 10,000 live births are affected by a brain or spine birth defect; in Haryana that translates to at least 2,400 babies a year. Adequate folic acid intake could drop the prevalence to six per 10,000 births.

About 75 percent of children with brain and spine birth defects die before their fifth birthday. Spina bifida, one of the birth defects that can be mostly prevented with folic acid, has varying degrees of severity. Children with spina bifida who survive past their fifth birthday often have life-long disabilities.


Grain fortification in Africa

While India, Afghanistan, Pakistan, and Solomon Islands are building their grain fortification programmes, many countries in Africa have required food fortification for several years.Legislation to require millers to fortify is a 'push' or top-down approach to fortification that does not always lead to nationwide fortification.

In 2018, FFI led a 'pull' project in Malawi and Uganda to involve stakeholders such as consumer associations and groups of parents of children with disabilities. The goal was to create consumer demand for quality, fortified foods.

FFI taught participants the value of fortification and asked them to gather market samples of fortified wheat flour, maize flour, and edible oil. The samples were tested with simple qualitative fortification tests. The samples that passed were sent to a laboratory for quantitative testing.

In both countries, a number of samples which were labelled as fortified were not actually fortified according to the qualitative tests. Quantitative testing showed that other samples that were fortified contained vitamin and mineral levels below the country's minimum amounts for compliance.

The pull strategy will complement the government's external monitoring and the industry's internal monitoring to create a robust process for ensuring that the population receives the intended vitamins and minerals from fortified food.

In another part of Africa, leaders from countries in the Southern African Development Community (SADC) came together in October 2018 and identified numerous approaches and tools available for a robust monitoring and surveillance framework for fortification programmes.

FFI is working with the SADC Secretariat to formalise the framework and move forward in key areas of support to each SADC country over the next four years. SADC Member States frequently trade grain products and having a uniform monitoring system among countries will enable consistent application and enforcement of quality measures.


Global fortification progress

FFI's annual survey for 2018 reports that 32 percent of the world's industrially milled wheat flour is fortified, up from 31 percent in 2017. The proportion of industrially milled rice increased from 0.8 percent in 2017 to 1.1 percent in 2018. The volume of industrially milled and fortified maize flour increased in 2018, largely due to increased maize flour fortification in Uganda.

The percent of industrially milled maize flour that is fortified decreased from 65 percent in 2017 to 54 percent in 2018 largely because FFI recalculated the amount of maize flour that is industrially milled.

The maps indicate the proportion of industrially milled grain fortified in each country. The WHO recommendations for wheat and maize flour note that if the estimated per capita consumption in a country is less than 75 grams-per-person-per-day, enough nutrients cannot be added to the grain to meet the nutritional needs of women of childbearing age. Consequently, countries where the food availability of each grain is less than 75 grams-per-person-per-day are not included in the maps.

In some countries, consumption patterns vary widely among urban and rural residents. FFI is taking a closer look at countries where the average consumption of one grain is less than 75 gramsper-person-per-day. In those places, consumption of industrially milled grain in urban areas may be high enough that fortification is an opportunity to improve health of urban residents.

To create or revise fortification documentation about legislation, standards, or monitoring, stakeholders can use a 44-point checklistpublished in 2018. Sample textis available for each item.

Upon reading this again, I think you could leave this out as the nutritional causes of anemia are in the next paragraph. It's correct, so you could leave it in, but if you need to save space, it could be deleted.

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