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. Fortifying grains with these vitamins and minerals can help prevent anemia caused by nutritional deficiencies.

If available, compare anemia data for men and women in your country. 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 (WHO) Vitamin and Mineral Nutrition Information System (VMNIS) Database on Anemia.

• Select your country from our country profiles for selected anemia data.

• When reviewing anemia data, refer to this classification of anemia as a public health problem from WHO:

• ≤4.9% No problem

• 5.0-19.9 Mild problem

• 20.0-39.9 Moderate problem

• ≥40.0 Severe problem

Neural Tube Defects

All people need folic acid (vitamin B9) to produce and maintain healthy cells and avoid a certain type of anemia. Women who may become pregnant are encouraged to consume 400 micrograms of folic acid daily to help prevent birth defects of the brain and spine, also called neural tube defects (NTDs).

Countries that fortify flour with folic acid generally reduce the NTD prevalence 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. NTD prevalence for only live births will misrepresent the NTD prevalence in all pregnancies.

Three types of birth defects are 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:

• 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 other research.

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. Read FFI's report "Vitamin A Stability After Wheat Flour Fortification" to learn more.

For data on vitamin A deficiency, see WHO's Global Prevalence of Vitamin A Deficiency in Populations at Risk 1995-2005. 

Zinc Deficiency

Zinc deficiency is one cause of childhood stunting, and zinc deficiency is also linked with diarrhoeal diseases, pneumonia, malaria.

WHO estimates that zinc deficiency affects about one-third of the world's population, with estimates ranging from 4% to 73% across subregions. Worldwide, zinc deficiency is responsible for approximately 16% of lower respiratory tract infections, 18% of malaria and 10% of diarrhoeal disease. About 1.4% of deaths worldwide were attributable to zinc deficiency.

See your country profile for the percent of the population at risk of inadequate zinc intake.

Food intake guides fortification nutrient levels

Learn what foods are frequently eaten in your country and set standards for the levels of nutrients to add via fortification based on this information.

Consider both the primary and secondary grains available. For example, rice may be the main cereal, but enough foods may be made with wheat that both rice and wheat flour fortification are needed.

To understand food intake, consider using these sources: 

• National food consumption surveys measure a population's food intake. They often use 24-hour recall methods and food frequency questionnaires. The surveys are often not available nationally. Other sub-national information is frequently available from ministries of health, non-governmental organizations, and nutrition departments at universities.

• Household Income and Expenditure Surveys (HIES) are multi-purpose instruments that usually report on grains, sugar, and oil. Note that expenditures do not always reflect consumption. Also, these are based on households rather than individuals, and the survey does not usually include foods eaten outside the home. The surveys can help determine geographic areas where a food is widely consumed. See this example from the Solomon Islands

• Panel surveys are sometimes conducted over time with representative households. These are usually annual. They can be used to track changes in food preferences and in a wide range of socioeconomic factors. Results are likely to be available from the National Bureau of Statistics. Some data sets are available from the International Food Policy Research Institute.

• Fortification Rapid Assessment Tools (FRAT) combine a simplified 24-hour recall and food frequency questionnaire. The six-part questionnaire provides a minimum amount of information about consumption patterns to help identify appropriate foods for fortification. FRAT questionnaire can be stand-alone surveys or added to an existing survey.

• Food Balance Sheets from the Food and Agriculture Organization of the United Nations (FAO) list food available per capita in a country. On the FAO website, choose the country, then the most recent year, and click “Show Data.” Or see our Country Profiles. The grain available data are from FAO. The amount for human consumption accounts for domestic production, imports, exports, grain that is stored or released from storage annually, grain used for animal feed, grain saved for seed, and grain that is wasted.

• The U.S. Department of Agriculture Foreign Agriculture Service has grain consumption data for some countries. On the website, under “categories,” choose “Grain and Feed.” Select the custom date and country. Then select the annual report from the results.

Oil and sugar are often practical food vehicles for vitamin A. Salt is commonly fortified with iodine. Milk often is fortified with vitamin D. Comprehensive food fortification programs will consider which foods or combination of foods have the potential to reach the largest number of people with the least cost. See the Global Fortification Data Exchange (GFDx) in English or in Spanish (en español). for information on oil and salt fortification in countries.

For More Information:

• Guidelines on Food Fortification with Micronutrients, published by the World Health Organization and FAO, is available in Chinese, English, and French.

• World Bank presentation at previous FFI workshop.

Milling infrastructure determines fortification feasibility

Our focus is fortifying wheat flour, maize flour, and rice in industrial mills. For wheat and maize, this means mills with a capacity of at least 20 metric tons a day. Rice is most easily fortified in mills with a production capacity of at least 5 metric tons an hour. Rice can also be fortified in large distribution channels such as government programs.

To plan a realistic fortification program, it is crucial to understand the country’s milling infrastructure. Many countries have national milling associations, and these groups are essential in the planning process. Industry leaders can help identify the number of mills in a country which helps determine the fortification training and implementation process.

While modern flour mills may already have equipment needed, older mills may require a significant capital investment to begin flour fortification. Equipment needed for rice fortification depends on the fortification technology chosen. See more about rice fortification in answers to frequently asked questions. 

For More Information:

• See a case study from Iran for an example of a comprehensive industry analysis.

• Smaller mills are sometimes called hammer mills or chakki mills. See resources for smaller mills.

Standards define nutrients and nutrient levels

When a country chooses to fortify cereal grains, it must decide what vitamins and minerals to include. It must also determine the levels of each nutrient to add. The results of these decisions are the basis for the country’s fortification standard.

Factors to Consider in Setting Country Standards

• Consumption: If consumption is high, lower amounts of nutrients are needed per kilogram of grain to create a positive health outcome. If consumption is low, higher levels are needed.

• Type of flour: High extraction flour (greater than 80%) is also known as whole wheat flour or atta flour. High extraction flour retains high levels of wheat’s natural phytates which inhibit the body’s ability to absorb iron and zinc. Consequently only the highly bioavailable sodium iron EDTA (NaFeEDTA) is recommended for high extraction flour. Also, the amount of zinc added to high extraction flour should be higher than the amount used for low extraction flour.

• Type of iron: The iron compounds recommended for wheat and maize flour fortification include ferrous sulfate, ferrous fumarate, and sodium iron EDTA (NaFeEDTA). Electrolytic iron is only recommended if flour availability is more than 150 grams per person per day. The iron compounds have different levels of bioavailability to consumers and different costs for millers. Ferric pyrophosphate is the iron compound most frequently used with rice fortification.

• Other food fortification: If other foods are effectively fortified and they reach the majority of the population, the nutrient may be left out of grains. For example, vitamin A is often added to vegetable oils or margin and not added to flour.

• Range: Effective standards specify a minimum and maximum level of each vitamin and mineral to use in fortification. This provides a level that can be expected to have a health impact while allowing some margin so that implementation is practical. Millers rarely exceed the maximum because it would be costly to do so.

• Sensory outcomes: Global recommendations for fortification are based on levels that will not affect the product's taste, smell, or appearance. If your country is considering a standard that exceeds the global recommendations, cooking trials may be needed to ensure that the fortification does not have a negative impact on the final food product.

Some people fear that iron could cause sensory problems at the levels recommended if flour consumption is less than 150 grams per capita per day. However a study of 15 kinds of noodles and breads commonly eaten in Asia showed that the foods would be acceptable to consumers if the food were made with fortified flour. The study included foods fortified with recommended iron levels for groups that eat less than 150 grams per capita per day.

A series of baking trials in Kenya, South Africa, and Tanzania showed that wheat flour and maize meal fortified using global guidelines caused no changes in the baking or cooking properties. Participants could not consistently perceive differences between fortified and unfortified products.

Muehlenchemie conducted tests to determine how different forms of iron affect the color of pasta. The company also analyzed the cooking water of the pasta with soluble iron forms. The results showed a loss 5% of iron in non-enriched pasta (natural value), a loss of 7% in enriched pasta with fumarate and sulfate, and a loss of 40% in EDTA-enriched pasta.

Global recommendations provide information on iron, folic acid, vitamin B12, vitamin A, and zinc levels for fortification. Regional recommendations may be available for fortification with thiamin, riboflavin, and niacin which are other B vitamins frequently added to flour. Also see a guide to setting fortification levels.

The minimal amount to restore the nutrients that were in wheat naturally but lost in the milling process are:

• Thiamin (vitamin B1): 6.4 parts per million (ppm)

• Riboflavin (vitamin B2): 4.0 parts per million (ppm)

• Niacin (vitamin B3): 53 parts per million (ppm)

Note: Parts per million equals milligrams per kilogram.

For More Information:

• Legislative frameworks for corn flour and maize meal fortification

• Presentation on fortifying with B vitamins, calcium, and magnesium.

• European Union guidelines and regulations in EU Reg. 1925:2006 and EU Reg. 1170/2009.

• Summaries of two workshops leading to the current global guidelines: Atlanta in 2008 and Mexico in 2004.

• Sample legislation and standards from several countries.