FFI Newsletter December 2012
Anemia and Neural Tube Birth Defects Decline in Bahrain
Progress Measured 11 Years After Fortification Began
Eleven years after beginning its flour fortification program, the Kingdom of Bahrain reports significant declines in anemia among pregnant women and in the prevalence of neural tube birth defects. Anemia among pregnant women dropped from 40% in 1996 to 23% in 2012. The prevalence of neural tube defects declined from 2.6 per 1000 live births to 0.9 per 1000 live births.
The Kingdom began fortifying flour with iron and folic acid in 2001 as one way to address nutrient deficiencies revealed in a 1996 study. In early 2012, Dr. Nadia Gharib, Head of Nutrition Section, led the creation of a “Flour Fortification Project Follow-Up.” The committee includes representatives of Bahrain Flour Mills, Ministry of Commerce represented by Consumer Protection Directorate, and the Standardization and Metrology Directorate.
In November 2012, the committee met for a consultation and revealed the data showing improvements in anemia among pregnant women and prevalence of neural tube defects. The data were obtained from health statistics released annually by the Health Information Dictorate-Ministry of Health. The prevalence of anemia and iron deficiency anemia in pregnant women is obtained through the antenatal nutrition surveillance program.
The committee’s next steps will be to review the fortification program's quality assurance, quality control, and monitoring systems. Future directions will be discussed, including the possibility of adding other vitamins and minerals to the country’s wheat flour standard.
The Kingdom of Bahrain is one of 75 countries that fortifies wheat flour with at least iron or folic acid. Fortifying staple foods such as wheat flour with iron reduces the risk of iron deficiency. Fortifying with folic acid, a B vitamin, lowers the risk of pregnancies being affected by a neural tube defect such as spina bifida.
Several countries in the Middle East have been fortifying wheat flour for more than 10 years now. Dr. Gharib and Amal Jassim Albinali, Standards Development Supervisor for the Standards and Metrology Directorate of the Ministry of Industry and Commerce, were among the participants at a workshop in February 2012 that encouraged countries in the region to review their country standards in light of current global guidelines. The workshop was hosted by the World Health Organization (WHO) and FFI with contributions from the Global Alliance for Improved Nutrition (GAIN), the Micronutrient Initiative (MI), and the U.S. Centers for Disease Control and Prevention (CDC). See a summary of the workshop.
Kosovo Begins Mandatory Fortification
Wheat Flour to Include Iron and Folic Acid
The first shipment of vitamin and mineral premix is expected to arrive soon in Kosovo, allowing it to begin implementation of a mandatory wheat flour fortification program. The law was approved and published in September, making Kosovo the 75th country to require wheat flour fortification with at least iron or folic acid.
A flour fortification standard, which is separate from the fortification legislation, calls for the addition of 20 parts per million of iron as ferrous sulfate and 1.0 parts per million of folic acid. Millers may voluntarily fortify flour with vitamin A, vitamin B12, and zinc.
The Flour Fortification Initiative (FFI) encourages countries to separate standards from legislation as Kosovo has done because standards are easier to modify if results from monitoring efforts later indicate the need for changes.
This standard has been fully embraced by the Ministry of Agriculture, Forestry and Rural Development, the Ministry of Health, the Ministry of Trade and Industry - department for standards, the National Institute of Public Health, the Flour Millers Association of Kosovo, and the Kosovo Food Agency. A quality assurance manual for the 70 operational mills has been created.
An estimated 1.7 million people live in Kosovo where bread and other wheat flour products are commonly consumed. Fortifying flour with iron can reduce the prevalence of iron deficiency anemia which leads to decreased work productivity and undeveloped cognitive ability in children. If severe enough, iron deficiency can lead to anemia which increases the risk of maternal mortality during childbirth.
Anemia can be caused by many factors, but in Kosovo the most likely cause of observed anemia is iron deficiency, according to a 2010 Nutritional Survey of Pregnant Women and School Children conducted by the National Institute of Public Health and supported by the UNICEF Kosovo Office. The survey showed 15.7% of school children ages 5 to 14 with anemia, and the prevalence did not differ significantly between gender or rural and urban residences. Anemia prevalence among the 900 pregnant women in the study was 23%.
UNICEF is a key partner in Kosovo. It provided the first shipment of premix, and it will continue to provide support through advocacy, marketing, and trainings. Kate Wheeler, Emory University graduate student and FFI research assistant, spent eight weeks in Kosovo in 2012, working with the UNICEF Kosovo office and fortification stakeholders, to develop a monitoring and evaluation plan for the fortification program. UNICEF Health and Nutrition Officer, Dr. Agron Gashi identified key stakeholders in Kosovo’s fortification program, and meetings were arranged with these partners s to discuss the roles and responsibilities of their respective institutions, and the resources needed to monitor fortification. Potential obstacles to establishing an effective monitoring and evaluation program were also identified. Information from these meetings, along with background information on the health system and salt iodization program, was then synthesized into a framework for a proposed monitoring and evaluation plan. A training event is tentatively planned for the first quarter of 2013. It will focus on complying with the standards and monitoring for quality and sanitation.
In June 2012, representatives from Kosovo attended a joint UNICEF/FFI workshop in Ankara, Turkey. In addition to sessions on quality and process control, legislation and standards, and monitoring and evaluation, country teams worked in groups to negotiate details of the monitoring process. All presentations, photos and a summary from the June workshop are available on the FFI website.
The Kosovo team also met with representatives from Albania and the Former Yugoslav Republic of Macedonia to discuss similarities in the fortification process and challenges faced. Representatives from each country are interested in greater regional collaboration. Suggestions from FFI staff attending the workshop were incorporated into the draft monitoring plan and presented to stakeholders in Prishtina, including:
- Tahire Maloku-Gjergji, Head of Human Ecology at the National Institute of Public Health
- Ilirjana Zymberaj, Director of the Inspectorate at the Food and Veterinary Agency
- Muhamet Farizi, leader of the Flour Millers Association
- Adem Arifaj, Ministry of Agriculture
- Safete Rexhepi, Ministry of Trade and Industry
- Merita Vuthaj, Ministry of Health
See more photos from the Kosovo milling and monitoring process.
Including Rice in FFI's Scope of Work
The Flour Fortification Initiative (FFI) began with a focus on wheat flour, but we are more and more frequently asked for solutions related to fortifying maize flour and rice as well. With approval from the Executive Management Team, FFI is expanding its scope of work to include these other cereal grains and seeking your feedback in this process.
As a first step, we are adding information related to rice fortification to the FFI website. See this new page under the “Implement Effectively” section and the answers to Frequently Asked Questions from the Rice Industry. The country profiles include information on rice production, trade, and consumption when the data are available. Each regional activity page mentions the status of rice fortification in that region.
We will rely on the network of partners for expertise in these fields. Please send information to be added to our growing list of network resources available regarding maize flour and rice fortification to email@example.com.
Share Your Lessons Learned in Past 10 Years
We celebrated FFI’s 10th anniversary in October as a 2002 Policy Planning Forum in Mauritius helped launch FFI. Our next step in observing this decade of progress through partnerships is to write an article about the lessons we have learned together.
We would like your contributions for the article. What have you discovered about flour fortification that leads to improved health among a population? What do you regard as essential elements of working together in a partnership? See your feedback to firstname.lastname@example.org.
If you missed the October news about the anniversary, here are the links:
- Celebrating 10 Years of Progress Through Partnerships
- Photos of Flour Fortification Throughout the Decade
- History of the Flour Fortification Initiatiive
ECSA Health Ministers Urge Mandatory Food Fortification
The Health Ministers of the East, Central and Southern Africa Health Community (ECSA HC) passed a resolution supporting mandatory food fortification during their meeting 13-14 December in Arusha, Tanzania. The resolution calls for seven actions, including one to "urge member states to implement mandatory food fortification programmes."
ECSA active member states include Kenya, Lesotho, Malawi, Mauritius, Seychelles, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe. Of those, only Kenya, Tanzania, and Uganda currently have mandates for wheat flour fortification.
Congratulations to Rey Martorell
Rey Martorell, Robert W. Woodruff professor of International Nutrition at Emory University and member of the FFI Executive Management Team, received the Gopalan Oration and Gold Medal Award from the Nutrition Society of India at its 2012 annual meeting. The meeting was held at Sri Venkateswara University in Tirupati, India, in November.
We join the Emory University faculty and staff in congratulating Rey on another recognition of his lifelong contribution to global nutrition.
Periodic Update December 2012 Table of Contents
Tentatively in February or March; contact Anna Verster, email@example.com
First and second quarter of 2013
Proposed Training Courses
Kosovo, Macedonia, Moldova, Albania; Contact Becky Handforth, firstname.lastname@example.org or Bob Baldwin, email@example.com
Hidden Hunger - From Assessment to Solutions International Congress
University of Hohenheim, Stuttgart, Germany
Training Program on Surveillance and Prevention of Birth Defects and Preterm Births