FFI Newsletter: December 2015
Photo: Benedicte Kurzen/UNICEF
Nigeria Adds Folic Acid to Fortification Standard
Now only 5 of 84 countries omit this essential vitamin
In October we received official documentation that Nigeria has added folic acid to its standard for wheat flour fortification. The national standard previously included iron and other nutrients but not folic acid (vitamin B9).
This change represents extensive advocacy work by multiple partners and national leaders in Nigeria. It is worth celebrating as fortifying flour with folic acid reduces the risk of children having severe neural tube birth defects by an average of 46%, according to one meta-analysis.
Now the only countries which omit folic acid from wheat flour fortification standards are the Congo, the Philippines, the United Kingdom, and Venezuela. Papua New Guinea also omits folic acid from its rice fortification standard. Globally 84 countries have legislation that mandates fortification of wheat flour, maize flour, or rice with at least iron or folic acid.
Folic acid helps a baby’s neural tube close very early in the pregnancy. The neural tube forms the child’s brain and spine. Neural tube defects include:
Anencephaly, which is fatal
Spina bifida, which causes paralysis and loss of sensation
Encephalocele, which is rare
In this new video, Godfrey Oakley, Director of the Emory University Center for Spina Bifida Research, Prevention and Policy, describes fortifying flour with folic as “the best thing since sliced bread.” He notes that fortification with folic acid also prevents anemia caused by folate deficiency. Another study from China suggests that supplementing with folic acid is instrumental in preventing first-time strokes as well.
In addition, preventing these birth defects has economic benefits. Children with spina bifida undergo a lifetime of surgeries and treatments. Preventing spina bifida averts these healthcare expenses.
The following recent publications illustrate challenges where fortification is not practiced:
A study published in November showed “no obvious downward trend,” in NTDs over 20 years in Europe. The study was based on data from the European Surveillance of Congenital Anomalies. No country in this surveillance system has a mandate to fortify wheat flour with folic acid.
That study found that “only a small minority” of women took a daily folic acid supplement if they might become pregnant. The author of an accompanying article noted that women may have 30 child-bearing years, and expecting them to take a supplement every day for 30 years is not realistic.
In Venezuela folate deficiency affects over 70% of the female population of child-bearing age, according to a summary of available studies. In contrast, nine years after fortification with folic acid began in Canada, less than 1% of the population aged 6-79 years had folate deficiency. Folate is the form of vitamin B9 that is in unfortified foods. The Venezuela summary was part of a supplement in the Anales Venezolanos de Nutrición.
Does Flour Fortification Really Impact Anemia?
You may have noticed conflicting studies recently about flour fortification’s effect on anemia from nutritional deficiencies. One study published in the British Journal of Nutrition (BJN) associated fortification with a 2.4% annual decline in anemia. Another study published in Nutrition Reviews showed fortification had some impact on iron status but not on anemia.
Richard Hurrell, Professor Emeritus for Human Nutrition, ETH Zurich, noted that most countries in the BJN article used bioavailable iron compounds at levels recommended by the World Health Organization (WHO). In contrast, most of the studies in the Nutrition Reviews article did not use WHO recommended iron compounds at the suggested levels. See this blog for further discussion of the two studies.
Fortification cannot be expected to impact iron deficiency anemia unless bioavailable iron compounds are included at appropriate levels. Endorsed iron compounds are ferrous sulfate, ferrous fumarate, and sodium iron EDTA. Electrolytic iron is only recommended if the wheat availability in the population is higher than 150 grams per person per day. For high extraction flour such as whole-grain or atta, sodium iron EDTA is the only recommended iron compound.
See Table 1 of the WHO recommendations for the suggested levels for each iron compound based on per capita grain availability. Each country’s estimated grain availability from the Food and Agriculture Organization of the United Nations is included in our country profiles.
For more information, see this new video of Reynaldo Martorell discussing the food fortification program in Costa Rica. Reynaldo is the Woodruff Professor of International Nutrition at Emory University and Senior Advisor to the Global Health Institute at Emory. He was the lead author of a study published in 2015 that concluded that fortification improved iron status and reduced anemia in Costa Rica.
Sample Legislation and Standards in Five Languages
We have posted examples of national legislation and standards on the FFI website for your reference. See samples from 17 countries. Documents can be found in one or two of these languages: English, French, Portuguese, Russian, or Spanish.
Developing legislation and standards are part of the planning process for successful fortification programs. Nutrition status, grain availability, industry capacity, and communications planning are other topics to consider. Contact us at info@ffinetwork.org for more information.
Flour Fortification Indicators Added to eCatalogue
The World Health Organization maintains an electronic catalogue of indicators to help track performance of micronutrient programs. Countries can now adapt and adopt process and impact indicators for flour fortification programs, as several new indicators related to this intervention were added this year. This new resource can be especially helpful for advisors or program managers engaged in monitoring and evaluation of flour fortification.
Scroll toward the end of the list of indicators to see those relevant to flour fortification. See this page for instructions on how to use the catalogue.