National Consultation on Wheat Flour Fortification
11 August 2015 - 12 August 2015
This two-day national consultation on wheat flour fortification recognized the health burden posed by micronutrient deficiencies. These include anemia from vitamin and mineral deficiencies and neural tube defects from insufficient folic acid. Plans to consider scaling up wheat flour fortification with iron, folic acid, and vitamin B12 across the country were considered, using open market channels and public funded programs as potential delivery platforms.
The objectives of this consultation were to:
- Review global and national scientific and programmatic evidence on feasibility and impact of wheat flour fortification in addressing micronutrient deficiencies with special focus on anemia and neural tube defects.
- Share state experiences on wheat flour fortification and select models and develop understanding of the wheat fortification strategy and institutional mechanisms for its effective implementation.
- Propose recommendations and plan a way forward to operationalize a framework for implementation of wheat flour fortification with iron, folic acid, and vitamin B 12.
Dr. Rakesh Kumar with the Indian Administrative Service, Joint Secretary, Ministry of Health and Family Welfare, Government of India, in his keynote address emphasized a national guideline for wheat flour fortification for promotion and consumption of wheat flour in India.
“When you talk about under-five mortality, anaemia is a major cause, more than 50% of women are anaemic, and anaemia is prevalent in more than 30% of the adolescent boys,” he said. “Also, neural tube defects are primarily caused by insufficient folic acid among women who may become pregnant. Distribution of iron and folic acid (IFA) supplements has come down to 20%, so IFA tablets are not a solution of this problem. Diet diversification is important and but we need fortification interventions along-side other programs.”
Dr. Coleen Boyle, Director of the National Center on Birth Defects and Developmental Disabilities at the US Centers for Disease Control and Prevention (CDC), in her opening remarks mentioned that the World Health Assembly identified neural tube defects (NTDs) as one of the underlying causes of deaths of children under 5 years of age. She reiterated that the majority of the NTDs could be prevented by adequate consumption of folic acid. She also noted that India’s rate of NTDs is about 6 times higher than that in the United States. In USA, the rate of NTDs is 0.7 per 1000 live births, compared to 4.5 per 1000 live births in India.
Dr. Amy Cordero, Public Health Analyst for the CDC, presented on ‘Global Evidence on Wheat Flour Fortification with Folic Acid for Prevention of Neural Tube Defects.’ She outlined the folic acid recommendations in United States and reduction of NTD rates before and after flour fortification with folic acid in US, Canada, Chile, Costa Rica and South Africa.
Jee-Hyun Rah, Nutrition Specialist with UNICEF, said in India, 50% of the populations of all age groups consume less than 50% of the recommended daily allowance (RDA) of vitamins and minerals. One exception may be iodine as India had a history of fortifying salt, and 70% of the populations now consume iodized salt.
Hameed Nura, World Food Programme India Representative, mentioned that 83 countries have legislation to fortify wheat flour, and WFP India is working with wheat flour fortification pilot projects in India to showcase implementation strategy.
Dr. Ajay Khera, Commissioner, Ministry of Health and Family Welfare, said in the last 40 years he has heard that supplementation is not affecting micronutrient deficiencies and NTDs in India. “It is now important that we take fortification into the National Health Mission (NHM). Fortification is top of our agenda, but we need to understand where the gap is. We have lessons learned on wheat flour fortification from couple of states in India. We also need to understand what the global standards on wheat flour fortification are and what we have in India,” he emphasized. He also mentioned for allocation of special funds for promotion of wheat flour fortification.
Dr. Rajan Sankar, Senior Advisor, Tata-Trust, said one-third of edible oil consumption was through the organized sector, and 10% of the population was already reached through fortification of edible oil with vitamin A. The Public Distribution System (PDS) uses 60 million metric tons of food grains annually, and it can potentially reach millions of population if PDS rations are fortified and distributed. He also mentioned that mandatory fortification is important, and it needs to be supported by strong regulatory mechanisms.
Dr. Angela De Silva, World Health Organization (WHO) Regional Advisor for Nutrition for Health and Development, discussed on the WHO guidelines on wheat flour fortification. The guidelines are based on scientific reviews prepared by experts from nutrition, public health, chemical engineering, flour milling industry and academic fields.
Dr. Neena Raina, Regional Advisor, Child and Adolescent Health of WHO, provided an update of birth defects in Southeast Asia and birth defects surveillance facilities in the network hospitals of these countries. She also encouraged promotion of food fortification in the context of high prevalence of micronutrient deficiencies, especially insufficient folic acid in pregnant women. ‘There were lot of evidences generated globally though wheat flour fortification and it worked well in many countries. We are not creating any more evidences but trying to look into the sufficiency of micronutrients through intake of fortified flour,’ she vehemently articulated.
Dr. Radhika Madhari, Scientist from National Institute of Nutrition (NIN), talked about the processes it undertook for developing standards on wheat flour fortification and explained how they reached to the calculations of various micronutrients based on the Indian RDAs. Many people questioned the levels of folic acid in the proposed India standard, as well as the inclusion of iron compounds not recommended for whole wheat flour. The ministry of Health of the Government of India is expected to take up this issue with the Food Safety Standards Authority of India (FASSI) to harmonize the WHO standards on wheat flour fortification with Indian standards. Staff from the regional and national offices of WHO have been following on this matter with the senior officials of Ministry of Health.
On the second day, Subrata Dutta, India Coordinator for the Food Fortification Initiative (FFI), presented an overview of wheat flour fortification in India, including the history of pilot flour fortification projects initiated by the agencies and efficacy trials. In the consultation, the Micronutrient Initiative, the Global Alliance for Improved Nutrition (GAIN), PATH, and WFP representatives presented their programs and evidences generated through fortification.
In conclusion, Dr. Ajay Khera informed that initially India’s wheat flour fortification guideline would focus on iron, folic acid and B12 to tackle the problem of anaemia and NTDs by increasing the intake of these nutrients. The Ministry of Health would ensure funding support for wheat flour fortification. He announced formation of a technical resource group which would work on wheat flour fortification guidelines.
The Ministry of Health and Family Welfare (MoHFW) and Government of India, in collaboration with the World Health Organization (WHO), UNICEF and World Food Programme (WFP).