FFI Newsletter September 2014
Cape Verde Passes Wheat Flour Fortification Legislation
After having voluntary wheat flour fortification for several years, Cape Verde passed mandatory fortification legislation on 1 August 2014. The country also updated its standard for wheat flour to be consistent with global and regional recommendations.
Previously, Cape Verde fortified wheat flour with electrolytic iron at 60 parts per million (ppm) and folic acid at 1.5 ppm. The new standard requires iron to be added at 60 ppm as ferrous fumarate or 40 ppm as sodium iron EDTA and for folic acid to be added at 2.6 ppm.
The one wheat flour mill in Cape Verde would have almost certainly voluntarily fortified its products per the new standard. Country legislation was necessary, however, to require fortification of imported flour as well as the domestically produced flour.
Cape Verde health officials, in partnership with the non-governmental group Helen Keller International, were the leading advocates for this change.
Now 80 countries have legislation to require wheat flour fortification. Twelve countries have legislation to fortify maize products, and five countries have legislation to require rice fortification. For maps that show the countries with mandates, view this page of the FFI website.
Pakistan's Punjab State To Begin Wheat Flour Fortification
16 million people expected to benefit
Wheat flour will be fortified with iron and folic acid in Pakistan’s Punjab state under a newly approved mandatory wheat flour fortification program. Planners expect that 1 million tons of fortified wheat flour will be on the market by December 2015 and will reach approximately 16 million people.
In Pakistan, the anemia prevalence among non-pregnant women is 27.9 percent and 50.9 percent among preschool children, according to the World Health Organization global database on anemia. As deficiencies in iron and other nutrients are a leading cause of anemia, fortifying with these vitamins and minerals can help prevent anemia.
Also, the March of Dimes estimates the number of pregnancies affected by neural tube defects is 20 per 10,000. Countries that fortify grains with folic acid usually report a neural tube defect birth prevalence of less than 10 per 10,000.
The legislative success is the result of collaboration among several partners, including the Punjab Food Authority, which is part of the Government of Punjab, the Punjab chapter of the Pakistan Flour Mills Association, and the Global Alliance for Improved Nutrition (GAIN). See more...
Updating wheat flour standard receives high-level endorsement
About 150 multi-sector leaders in Indonesia met 27 August in the country's first high-level meeting on food fortification. They discussed the current food fortification programs which include salt, wheat flour, palm cooking oil and rice.
Wheat flour fortification has been mandatory in Indonesia since 2001, but the group noted that the potential impact may be reduced because the amount of fortificants added to the flour is too low for some nutrients. Also, the type of iron added to flour is not easily absorbed. Changes to the national standard have been considered for some time. Leaders at this meeting agreed to update the national standard, taking into account World Health Organization recommendations and wheat consumption per capita in Indonesia. This represents the highest level, cross-ministry agreement on this issue to date.
The rice fortification program is currently a small pilot within a national subsidized rice program for the poor. It was not evaluated because it was launched in August this year. The efficacy and effectiveness of the intervention will be measured before the feasibility of expanding the pilot to the entire subsidized program is explored.
A full report from the meeting is online.
Scaling Up Rice Fortification in Asia
The newest research in rice fortification and practical ways to implement the findings were highlighted in a “Scaling Up Rice Fortification in Asia” workshop 16-19 September in Thailand. Nearly 200 people attended the meeting. They represented Bangladesh, Cambodia, Indonesia, India, Laos, Myanmar, Nepal, the Philippines and Sri Lanka as well as international partners.
Country representatives touched the globe to officially open the "Scaling Up Rice Fortification in Asia" workshop in Bangkok. Photo by the organizing committee photographer.
Rice is the staple food for 3 billion people in the world, most of whom live in Asia. Countries in South Asia also report some of the world’s highest prevalence of anemia and estimates of neural tube birth defects. Consequently, fortifying rice has great potential for preventing both anemia caused by nutritional deficiencies and birth defects caused by insufficient folic acid.
“Fortification of basic foodstuffs isn’t a new concept,” states Kenro Oshidari, Regional Director for Asia of the United Nations World Food Programme (WFP). “Wheat flour, maize flour and salt are routinely enriched with micronutrients in many countries – often with government regulations enforcing the practice. It’s been demonstrated that it is possible and economically viable to do this on a large scale, with significant public health benefits. Progress in technology means that now this is a possibility for rice fortification as well.”
The conference was co-organized by the Food Fortification Initiative (FFI; formerly the Flour Fortification Initiative), the Global Alliance for Improved Nutrition (GAIN), the Micronutrient Initiative (MI), PATH, the United Nations Children’s Fund (UNICEF) and WFP. A final report from the "Scaling Up Rice Fortification in Asia" meeting is being drafted for a future supplement of Sight and Life. See the commentary below from FFI Director Scott Montgomery about the partnership reflected in this event.
Behind the Scenes in Bangkok
Comments by Scott J. Montgomery, FFI Director
A few years ago I saw a presentation by a World Bank representative showing a hundred road signs pointing haphazardly this way and that way. She used this as an analogy for how many countries feel when they are bombarded with different messages on nutrition from non-governmental organizations, United Nations agencies, other government aid programs and academic institutions. It has to seem schizophrenic.
In contrast, the Scaling Up Rice Fortification organizing committee made it clear that this would be a different meeting. We would speak with one voice and leave out our personal opinions and agendas.
This was all due to the exhaustive work of the organizing committee with representatives from FFI, PATH, WFP, MI, UNICEF and GAIN. All speakers came two days in advance of the meeting to give their presentations to the organizing committee and other speakers. Presentations were agreed to and finalized with feedback from the entire group.
As a speaker, this was a humbling experience. I thought I had things finalized but ended up making many changes at the last minute. This happened to all the presenters. We all made some compromises but left the room of one mind.
This was successful because the organizing committee insisted that all presentations were on behalf of the group rather than individual organizations. A glossary of terms was developed, and every presentation used common language. Getting everyone around one table in this manner forced all of us to speak as one. It was a stressful experiment with a fabulous outcome.
|The team from Myanmar discusses rice fortification as apossible means of improving public health. Photo by Helena Pachón.|
The day prior to the official meeting kick-off, all country facilitators and focal points joined the presenters to further outline responsibilities. Country facilitators and focal points were given precise instructions for each of four country specific workshops as well as training tips on keeping the groups focused and on task.
Finally the official meeting started with nearly 200 attendees. A clear balance was struck throughout the next four days between presentations, country workshops, and innovative group exercises to keep our blood flowing and minds engaged. All country delegations had a mix of public/private sector participants. At the end of each day, all speakers, country facilitators, country focal points and the organizing committee met to discuss the day’s progress and the next day’s agenda. Things were modified as needed.
Overall it was one of the most well-thought-out and organized meetings I have attended. My gratitude goes out to the organizing committee in making this happen; they worked countless hours with equal passion to make for a fabulous meeting.
My prediction is that in a few years we will look back at Bangkok 2014 as a key milestone in scaling up rice fortification.
Newly Published Rice Fortification Resources
A meeting on technical considerations for rice fortification in public health was held in 2012. Soon all articles from the meeting will be published in a special issue of the Annals of the New York Academy of Sciences. Until then, the following individual articles can be downloaded:
- Considerations for rice fortification in public health: conclusions of a technical consultation
- Rice fortification: a comparative analysis in mandated settings
- Proposing nutrients and nutrient levels for rice fortification
- Review of the cost components of introducing industrially fortified rice
- Rice industrial processing worldwide and impact on macro- and micronutrient content, stability, and retention
- An overview of global rice production, supply, trade, and consumption
- Fortification of rice: technologies and nutrients
- Organoleptic qualities and acceptability of fortified rice in two Southeast Asian countries
- Stability and retention of micronutrients in fortified rice prepared using different cooking methods
Please contact us at firstname.lastname@example.org if you have difficulties downloading the files.
Feedback Needed for Global Updates
We are seeking your feedback in two areas to help update our global progress. The first is the percentage of wheat flour, maize flour, and/or rice that is fortified in your country. The second regards the monitoring practices of countries with mandatory grain fortification programs.
For 10 years, FFI has tracked the percent of industrially milled wheat flour that is fortified with at least iron and/or folic acid. To do this, we need estimates from each country about how much industrially milled wheat flour there is fortified. This will be the first year that we are attempting to gather similar data for industrially milled maize flour and industrially milled rice.
For the monitoring project, we will ask questions to understand what documentation and procedures are in place to monitor grain fortification programs.
We will use the email address of email@example.com to gather this information. Look for a message from this address in the coming weeks. We look forward to your collaboration in estimating the reach of fortified grains worldwide.
Optimal Blood Folate Concentration Determined
The optimal blood folate concentration for the prevention of neural tube defects is 1000 nanomoles per liter (nmol/L) or greater, according to research published in July by the British Medical Journal. Folate is the form of vitamin B9 found in foods naturally. Folic acid is the form of vitamin B9 used in fortification and supplementation.
Researchers found that the risk of a pregnancy being affected by a neural tube defect decreased as blood folate levels increased. The risk was substantially reduced when blood folate levels were 1000 nmol/L or higher.
The primary authors of this paper are researchers with the US Centers for Disease Control and Prevention (CDC) National Center on Birth Defects and Developmental Disabilities. A key finding, according to the CDC, is that “blood folate concentrations alone (without having information on folate intake or other factors) can be used as a tool to determine the need for and the effectiveness of neural tube defects prevention programs, such as the fortification of staple foods with folic acid.” See more key findings.
Answers to Questions about Vitamin D and MTHFR Genotype
Since the last newsletter in June, we have been asked about the following topics. In case you have the same questions, here are answers from experts among our partnership.
Q. What countries fortify with vitamin D, how much is added, and how is vitamin D monitored?
A. The countries that currently fortify wheat flour with vitamin D are Jordan, Saudi Arabia, and Palestine. Iran is considering adding vitamin D to its flour standard, and if Mongolia starts mandatory wheat flour fortification, it will likely include vitamin D.
The Gulf Country Council Standard calls for 2 micrograms of vitamin D to be added to 200 grams of flour. The Official Method for Analysis of vitamin D in wheat flour may be purchased online.
Humans produce vitamin D when skin is exposed to sunlight. Vitamin D is essential for healthy bones. Its deficiency can lead to rickets and contribute to osteoporosis. Vegetable oil is also frequently fortified with vitamin D, usually at 17 international units of vitamin D3 per gram of oil.
Q. If a high percentage of the country’s population has the Methylene-Tetra-Hydro-Folate-Reductase (MTHFR) gene, should flour fortification include folic acid?
A. Some people with a variant of the MTHFR gene process folate more slowly than others. However, with daily folic acid intake, the blood folate concentrations can increase regardless of MTHFR genotype.
Women who may become pregnant are encouraged to consume at least 400 micrograms of folic acid a day to help prevent neural tube defects such as spina bifida and anencephaly. Fortifying with folic acid has been shown to reduce the prevalence of these birth defects by an average of 46 percent. Also, folic acid deficiency is one cause of nutritional anemia. This type of anemia has been nearly eliminated in the United States since grain products have been fortified with folic acid.
Some discussion of MTHFR is included in the paper recently published on optimal blood folate levels.
New Resources for Small Scale Fortification
While FFI’s focus is fortification in industrial mills, in some places fortification in small mills is considered. Two new pieces of information are available for fortification in small mills:
- A video about small-scale flour fortification with iron – a rural pilot project in Kenya.
- A video, diagram, and answers to frequently asked questions about Sanku's device for fortifying in small-scale flour mills.
See a list of more resources for fortification in small mills.
Congratulations to Smarter Futures and GAIN
Two projects related to grain fortification received the highest performance ranking possible in an evaluation of Schokland and Millennium Agreements. The Smarter Futures partnership for Africa and the Global Alliance for Improved Nutrition (GAIN) Premix Facility were among seven projects rated as having “very good overall performance.”
The Dutch Ministry of Foreign Affairs organized the Pact of Schokland in 2007 to accelerate Dutch contributions towards the Millennium Development Goals. The related projects were evaluated in an effort to improve public-private partnership policy in the context of development cooperation and trade. In the evaluation final report released in March 2014, Smarter Futures and the GAIN Premix Facility both received a ranking of 96 percent based on a weighted composite score of development results, sustainability, and innovation.
The Smarter Futures partnership has contributed to the success of wheat and maize flour fortification in Africa with advocacy, training, technical support, and guidance on standards harmonization. Smarter Futures partners include AkzoNobel, the International Federation for Spina Bifida and Hydrocephalus, Helen Keller International, and FFI.
In addition to the official Smarter Futures partners, success in Africa reflects the commitment of multiple groups involved in implementation. This includes numerous non-governmental groups, country government leaders, flour millers, and civil society organizations.
Premix is the blend of vitamins and minerals added to flour in the fortification process. The GAIN Premix Facility reviews providers of vitamin and minerals used in food fortification and certifies those which meet quality guidelines. Through this step and a competitive procurement process, the facility helps ensure a reliable supply of affordable, quality vitamins and minerals for food fortification.
The Schokland assessment highlighted the important role and impact of the GAIN Premix Facility in its three areas of focus: procurement, quality, and financial access for premix. It also noted GAIN’s and the Premix Facility’s recent growth into broader quality assurance and quality control technical assistance.
FFI Newsletter September 2014 Table of Contents
- Cape Verde Passes Wheat Flour Fortification Legislation
- Pakistan's Punjab State To Begin Wheat Flour Fortification
- Indonesia Progress
- Scaling Up Rice Fortification in Asia
- Behind the Scenes in Bangkok
- Newly Published Rice Fortification Resources
- Feedback Needed for Global Updates
- Optimal Blood Folate Concentration Determined
- Answers to Questions about Vitamin D and MTHFR Genotype
- New Resources for Small Scale Fortification
- Congratulations to Smarter Futures and GAIN
All India Institute of Medical Sciences, Ansari Nagar
Radisson Blu Waterfront Hotel