FFI Newsletter June 2014
Congo Passes Legislation to Fortify Wheat Flour
Congo is the newest country to approve legislation to require fortification of industrially milled wheat flour. Now 79 countries have legal mandates for wheat flour fortification, 12 require maize flour fortification, and five legislate rice fortification. See updated maps on the Global Progress page.
The legislation requires the addition of iron as either ferrous sulfate or ferrous fumarate, said Eugène Loubaki, Coordinator of the National Commission for Food Fortification. The addition rate is 60 parts per million. Including other nutrients is voluntary. Eugène said the National Commission is working with the country UNICEF office and other stakeholders to be sure the imported flour is fortified as well.
Congo has one industrial mill, and it provides 60% of the country’s market for wheat flour. The mill is owned by Minoco, a Seaboard-affiliated company. The company voluntarily fortified flour for years before the legislation was passed.
Five delegates from the Republic of Congo attended FFI’s first African Network Meeting in Arusha, Tanzania, in 2008. Within a month, the country had developed a ‘roadmap’ for using fortification to reduce the prevalence of iron-deficiency anemia among children and pregnant women.
Country leaders will be included in upcoming training sessions on conducting a cost benefit analysis and using FORTIMAS, a tool to track trends in household coverage of fortified products and potential health outcomes.
Download New Toolkit for Guidance with Advocacy and Social Marketing Campaigns
A new Fortification Communications Toolkit is available to guide proponents in developing social marketing programs. An accompanying workbook includes templates to help organize the communications strategy. Both free tools can be downloaded from the FFI website.
Effective grain fortification requires systematic changes among various audiences - policy makers to approve legislation and standards, millers to regularly purchase and use premix, consumers to consistently consume fortified foods, and food safety authorities to continually monitor for quality. The new Toolkit offers an outline for a communications strategy to motivate key leaders to make and sustain these necessary changes.
Traditional marketing uses proven techniques to sell products, and social marketing draws on those techniques to influence behavior for improved health. While social marketing is often considered only for consumer communications, the new toolkit recommends using social marketing concepts throughout the advocacy process as well.
The toolkit includes guidance on:
- Identifying specific target audiences
- Setting objectives for each group
- Researching the audience’s perceived barriers and benefits related to fortification
- Creating a logo, messages, and activities
- Monitoring and evaluating the communications activities
The toolkit is based on country experiences as well as a literature review of communications related to fortification. Professional guidance was provided by the Atlanta, USA, staff of Porter Novelli, a public relations firm, as well as a global health communications professor at Emory University in Atlanta.
Celebration and Opportunity in Indonesia
The family of an international nutrition expert in Jakarta, Indonesia, had quite a surprise in June 2013 when they learned they were expecting a child. “This little baby was so very welcome but at age 43, the pregnancy was not really planned,” said the mother, Annoek van den Wijngaart.
“After the first joy, I felt nervous and worried. I had not taken folic acid supplements as recommended,” Annoek recalled. She wondered if the baby would be healthy. She worried about the risk of spina bifida, one of the neural tube defects that is usually prevented if the mother has 400 micrograms of folic acid daily before conception and in the early stages of pregnancy.
“Through my work with FFI, I suddenly realized how lucky I am to live in a country which has had mandatory flour fortification with folic acid for exactly this reason: many pregnancies are unplanned and/or women do not realize they have to take folic acid supplements (often in combination with iron) before they want to become pregnant,” Annoek said.
|Annoek van den Wijngaart's healthy daughter, Hanna, was born on 6 February 2014.|
Wheat flour fortification in Indonesia was mandated in 2001 and became effective in 2002. Folic acid is included in the national standard for fortification because all people need this B vitamin for cell development and to prevent folate-deficiency anemia. Other nutrients in the Indonesia standard are iron, zinc, thiamin and riboflavin.
“People in Indonesia, including temporary residents like myself, consume wheat flour in instant noodles, bread, and fried snacks,” Annoek said. When made with fortified flour, these foods provide extra nutrition to the population.
A review of Indonesia’s standards, however, reveals an opportunity for improvement. The type of iron required for fortification is not specified in the national standard. Consequently, the least expensive – and least bioavailable – form of iron is typically used. Also, the levels of zinc and folic acid are lower than the 2009 World Health Organization (WHO) recommendations.
In May 2014 an Emory University graduate student in the Rollins School of Public Health completed a thesis that estimated the contribution of wheat flour fortification to changes in anemia prevalence in Indonesia. The student accessed data from 5,828 non-pregnant women in the Indonesia Family Life Survey. This longitudinal study followed more than 30,000 Indonesians and included hemoglobin measurements as well as data on food purchases.
Anemia prevalence among non-pregnant women in the study before fortification (1997 and 2000) was 34%. After fortification (2007), anemia prevalence among this group was 25%. Wheat flour fortification, however, was not significantly associated with the decline, according to the thesis research. The reason for the decline was not part of the student’s research, but some have speculated that it is linked to improving economic conditions in Indonesia.
The post-fortification prevalence of 25% anemia among non-pregnant women is high enough to still be considered a moderate public health problem based on WHO classifications. Also, data in the study only reflect the study population. The only nationally representative data show the anemia prevalence among non-pregnant women in Indonesia to be 33%.
To make further progress in reducing the anemia prevalence, the student’s research supports the recommendation for a more bioavailable form of iron and additional iron, zinc and folic acid in the national standard. See the thesis abstract or e-mail firstname.lastname@example.org for a full copy of the thesis.
In August the Indonesia Ministry of Planning will hold a meeting about the country’s mandatory fortification programs for salt, wheat flour, and oil. This could be an important step toward changing policies so that fortification has a greater impact on the Indonesian population.
Contact Us for FFI Micronutrient Forum Presentations
The Micronutrient Forum in Ethiopia 2-6 June was a whirlwind of learning and networking opportunities. See a short summary of the event; presentations will be posted at a later date.
FFI’s staff presented five oral presentations and five scientific posters. A summary of the items is below. Please contact email@example.com if you would like to receive the full presentation or poster.
The Global Alliance for Improved Nutrition (GAIN) sponsored a symposium on large-scale fortification prior to the forum. The FFI presentations included:
- Review of effectiveness of wheat and maize flour fortification programs on iron status and anemia outcomes in developing countries. While the efficacy of flour fortification for improving iron status and anemia has been established and reviewed, the public-health effectiveness of flour fortification programs has not been reviewed. This presentation outlined the results from a global review of countries' flour fortification programs and their impact on iron status and anemia.
- The enabling environment: partnerships and mandatory legislation for flour fortification in Africa and their relevance for program outcomes. In 2011, FFI estimated that only seven countries in Africa were fortifying at least 75 percent of their domestically produced wheat flour with at least iron and folic acid. Now, we estimate that 21 countries have reached that level of fortification. This presentation discussed the environment that fostered that progress.
FFI presentations during the forum’s concurrent sessions included:
|Pam Liu, right, discusses a poster on food fortification in India with a Micronutrient Forum participant.|
- Food fortification in India: A literature review. The review process identified 47 relevant papers. Food fortification research in India suggests it improves biological markers, particularly iron and hemoglobin status, when fortifying with multiple micronutrients or iron. Salt iodization showed consistent positive results on iodine status.
- Analyzing the association between flour fortification and world-wide anemia prevalence. After adjusting for several factors, the evidence suggests anemia prevalence has decreased significantly in countries that fortify flour with micronutrients, while remaining unchanged in countries that do not.
- Regulatory monitoring systems of fortified salt and wheat flour in selected ASEAN countries. This analysis shows that without appropriate enforcement and quality assurance mechanisms in place to stimulate compliance by food producers, having national legislation will not necessarily lead to increased coverage of fortified products and associated outcomes. See the published report.
- Implementation of World Health Organization (WHO) recommendations on wheat and maize flour fortification in Asia. Countries in the region have been slow to implement the WHO recommendations for a variety of reasons. This presentation reviews lessons learned as FFI supports countries in updating and/or creating legislation.
- Monitoring of flour fortification programs: Case studies in three countries. Few flour fortification monitoring systems have been detailed in their entirety. This study described the monitoring systems in South Africa, Indonesia, and Chile; including the strengths and challenges of each system and the lessons learned.
- Fortification of wheat flour and maize meal with different iron compounds: Results of a series of baking trials. Common wheat-based foods in Kenya, South Africa, and Tanzania were made with flour that had been fortified with iron compounds included in 2009 WHO recommendations. Following recommendations did not lead to changes in the baking and cooking properties of the wheat flour and maize meal. See the published report.
- Contribution of wheat flour fortification to reducing anemia in Indonesia. This poster was based on the master’s thesis project described in the story above. See the thesis abstractt or e-mail firstname.lastname@example.org for a full copy of the thesis.
- Common Asian wheat flour-based foods: impact of flour fortification on processing factors and organoleptic properties. This study shows that fortified foods were acceptable to consumers, and several iron compounds could be used successfully. See the published report.
Workshop Provides Regional Training in Wheat Flour Fortification
A Quality Assurance / Quality Control (QA/QC) workshop in May combined presentations with group discussions and practical application at a local flour mill. Participants included 22 people representing the milling industry and public sector.
Some countries represented at the regional workshop have begun fortification but had not had QA/QC training. These included Benin, Mali, Morocco, Senegal, Togo and Yemen. Participants from Burundi, Djibouti, Iraq, Pakistan and Sudan requested additional technical support for this process. Cheick Oumar Kouma who works for Grands Moulins of Mali wrote to program organizers to say he was “very pleased with the quality of training.”
The meeting was organized in collaboration with the World Health Organization Eastern Mediterranean Regional Office, Smarter Futures (a partnership for Africa of the International Federation for Spina Bifida and Hydrocephalus, AkzoNobel, Helen Keller International, the Government of the Netherlands, and FFI), and the Global Alliance for Improved Nutrition (GAIN).
Many thanks to Institut de Formation de l'Industrie Meunière (IFIM) for hosting the practical application sessions.
New York Times Opinion Piece on Fortification Points to 'Certain Irony'
An opinion piece in the New York Times on 6 June noted the irony of European countries funding fortification efforts around the globe but not fortifying grains for their own population.
The article focuses on fortifying wheat flour with folic acid to prevent neural tube birth defects such as spina bifida. The United Kingdom (UK) is the only country in Western Europe with a mandate to fortify wheat flour. Currently the standard includes iron, calcium, niacin, and thiamin but not folic acid.
Jeff Rooker, a member of the House of Lords, is pushing for fortification to include folic acid. The British Pregnancy Advisory Service, an abortion provider in Britain, has also joined the effort. Ann Furedi, the service’s chief executive, was quoted in another article as saying: “The fortification of flour with folic acid is a straightforward public health intervention which could spare hundreds of women every year from the painful decision to end a wanted pregnancy after a diagnosis of a neural tube defect.”
A letter from the UK Department of Health dated April 2014 indicates the decision about whether to add folic acid to wheat flour will depend, in part, on results from a survey about the population's blood folate status. Those results should be available in early 2015, according to the letter.
Access Complete Maize Fortification Reports
In April 2013, a consultation was held on technical considerations for maize flour and corn meal fortification in public health. Free online access is now available for most of the 10 articles resulting from that consultation. Please contact email@example.com if you need information about maize fortification that you cannot access here.
FFI helped organize the meeting, and we appreciate the Sackler Institute for Nutrition Science and World Health Organization for making the online publication possible.
How Much Sodium Iron EDTA Should Be In Food for Children?
How much sodium iron EDTA to recommend for wheat and maize flour fortification programs is well established (see the World Health Organization recommendations and a Food and Nutrition Bulletin supplement). This highly bioavailable form of iron is the only compound recommended for use in high extraction or whole wheat flours such as atta flour.
The amount of sodium iron EDTA, also known as NaFeEDTA, to use in complementary foods for infants and young children is also established, but some argue that the level is too low. See this opinion piece written by Carel Wreesmann who works for Akzo Nobel Functional Chemicals, one of the manufacturers of sodium iron EDTA for food products.
FFI Newsletter June 2014 Table of Contents
- Congo Passes Legislation to Fortify Wheat Flour
- Download New Toolkit for Guidance with Advocacy and Social Marketing Campaigns
- Celebration and Opportunity in Indonesia
- Contact Us for FFI Micronutrient Forum Presentations
- Workshop Provides Regional Training in Wheat Flour Fortification
- New York Times Opinion Piece on Fortification Points to 'Certain Irony'
- Access Complete Maize Fortification Reports
- How Much Sodium Iron EDTA Should Be In Food for Children?
All India Institute of Medical Sciences, Ansari Nagar
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