Use Nutrition Data to Plan Fortification Strategy

Nutritional anemia and neural tube defects are the two most common health concerns addressed by fortification. Data from your country on these two issues will help determine if fortification could be a helpful strategy. 

Nutritional Anemia

Anemia can be caused by many factors, including deficiencies in iron, folic acid, zinc, riboflavin, vitamin A, and vitamin B12[1]. Fortifying grains with these vitamins and minerals can help prevent anemia caused by nutritional deficiencies.

Compare anemia data for men and women, if available. Women in their childbearing years are more prone to anemia than men. If anemia among women ages 15 to 49 is higher than anemia among men in the same age group, then the anemia is most likely a result of iron deficiency. In that case, fortifying with iron will most likely make people less prone to iron deficiency anemia.

If men and women in the 15-49 age group have similar anemia statistics, then other factors such as other nutritional deficiencies or malaria or parasitic infections are probably causing the anemia. Other interventions will be necessary to reduce anemia in these populations.

Young children are especially vulnerable to iron deficiency between the ages of 6 and 24 months. Other health interventions may be needed for this age group.

For more information:

Look for anemia results on Demographic and Health Surveys.

See the World Health Organization Vitamin and Mineral Nutrition Information System (VMNIS) Database on Anemia.

See our country profiles for selected anemia data.

When reviewing anemia data, refer to this classification of anemia as a public health problem from the World Health Organization:

≤4.9% No problem
5.0-19.9 Mild problem
20.0-39.9 Moderate problem

Severe problem

Neural Tube Defects

All people need folic acid, a B vitamin, to produce and maintain healthy cells and avoid a certain type of anemia. Women who may become pregnant are encouraged to get 400 micrograms of folic acid daily to help prevent neural tube defects (NTDs) such as spina bifida and anencephaly.

Countries that fortify flour with folic acid generally reduce the prevalence of these birth defects to less than 10 per 10,000 births. When looking for NTD data, consider whether the results include loss of pregnancy or termination of pregnancy due to an NTD diagnosis. Be aware that NTD rates for only live births will misrepresent the prevalence of NTDs in all pregnancies.

Three types of birth defects are considered NTDs: spina bifida, anencephaly, and cephalocele. The International Classification of Diseases (ICD)  codes for those are:

  • Anencephaly - ICD11 LA00.0-LA00.Z
  • Cephalocele - ICD11 LA01
  • Spina bifida - ICD11 LA02.0-LA02.Z

Hospital systems may be able to provide data on birth defects based on those codes.

For more information:

World Health Organization publication on using serum and red blood cell folate concentrations for assessing folate status in populations.

Some countries have entries in the Annual Report from the International Clearinghouse for Birth Defects Surveillance and Research.

For 21 countries in Europe, see the EUROCAT European Surveillance of Congenital Anomalies.

Country profiles on our website list NTDs per 10,000 births based on the above resources where available or estimates from the March of Dimes.

Vitamin A Deficiency

Vitamin A deficiency diminishes the ability to fight infections, and it is the leading cause of childhood blindness. Vitamin A deficiency may also lead to anemia. Vitamin A can be added to wheat or maize flour, but it shortens the flour’s shelf life and increases the cost of flour fortification. Consequently vitamin A is more frequently added to rice, oils, margarine, or sugar.

For data on vitamin A deficiency, see the World Health Organization Vitamin and Mineral Nutrition Information System (VMNIS) Database on Vitamin A Deficiency.

Zinc Deficiency

Zinc deficiency is one cause of childhood stunting, and it is also linked with diarrhoeal diseases, pneumonia, malaria. For county-specific estimates of stunting in young children, see the World Health Organization Global Health Observatory Data Repository

When reviewing stunting data, refer to these prevalence cut-off values from the World Health Organization:

< 20% Low prevalence
20-29% Medium prevalence
30-39% High prevalence
≥40% Very high prevalence

[1] Nutritional Anemia, Sight and Life Press 2007

For guidance on determining a country's nutritional needs, contact Helena Pachon, FFI Senior Nutrition Scientist, at

Micronutrient Survey Toolkit

Resources to help assess and monitor vitamin and mineral deficiencies are available in a Micronutrient Survey Toolkit. Sample topics covered include a laboratory overview, data and sample collection procedures, supplies needed, and hiring personnel. Each module includes tools that can be used as needed and examples of the tools used in different contexts.