Evidence-based nutrition interventions such as flour fortification can achieve tremendous impact. However, this impact isn’t automatic: new evidence is now showing that flour fortification programs not implemented properly will not achieve the public health impact desired. This shouldn’t come as a surprise to development professionals, but it is an important insight for designing and reviewing food fortification programs.
Food fortification – adding essential vitamins and minerals to staple foods and condiments like wheat flour or salt – is an effective intervention to fight micronutrient malnutrition. It has been hailed as one of the most cost-effective solutions to help improve nutrition by leading economists at the Copenhagen Consensus. It has the huge advantage of being able to deliver nutrients to large parts of populations, without requiring people to change their diets.
Thanks largely to food fortification with B and D vitamins in the west over the last century, we no longer commonly hear about micronutrient deficiency disorders like rickets, beri-beri and pellagra. In Africa and Asia, momentum has picked up in the last two decades to include food fortification as part of national strategies to improve intake of essential micronutrients like vitamin A, iodine, iron, and folic acid.
Fortifying wheat or maize flour with folic acid, a vitamin needed especially by women who may become pregnant, significantly reduces the risk of neural tube birth defects (NTDs). The most commonly known NTD is spina bifida, the failure of the neural tube to close properly in early pregnancy, causing permanent, incurable damage to the baby’s spinal cord.
NTDs affect approximately 300,000 people each year worldwide, the majority of cases preventable through adequate folic acid intake. Several studies document the effectiveness of folic acid fortification in reducing prevalence of NTDs. Iron is another critical mineral missing in diets worldwide. Anemia from iron deficiency contributes to 20% of all maternal deaths.
Flour fortification with iron has been shown clearly to improve iron status in controlled trials. But in actual practice, it gets more complicated. This is partly because as opposed to folic acid, which only has one “form” used in fortification, different types of iron can be used for flour fortification, each with different levels of absorption, or “bioavailability”. For this reason, it’s critical to ensure that the correct form of iron is being used.
The World Health Organisation (WHO) developed a set of recommendations to address this, and it is key that programs follow these guidelines in order to be effective.
Two recent papers which have sparked some debate on the effectiveness of iron fortification highlight the need to follow these recommendations:
• One study published in the British Journal of Nutrition (BJN) found that each year of fortification was associated with a 2.4% decline in anaemia prevalence in the population. Countries that did not fortify flour only had a 0.1% decline in anaemia prevalence over time.
• Meanwhile, a systematic review in Nutrition Reviews provided little evidence that fortification reduced anaemia prevalence.
A key difference between the two papers is that most of the countries in the BJN study used WHO-recommended forms and levels of iron. In contrast, most of the studies in the systematic review did not. We shouldn’t be surprised that without using the right form of iron, programs had little effectiveness: an expert review from 2010 predicted this exact outcome.
In addition, the systematic review reflected a wide variety of compliance and the percent of population consuming fortified flour. The issue of low compliance has also been recently documented in Global Health: Science and Practice: in 12 countries with data, less than half of the samples tested were compliant with standards.
No fortification program will have an impact if the forms of iron used are not bioavailable, insufficient iron amounts are used, if the program is not well-monitored, or if a high proportion of the population does not consume the fortified foods.
The Global Summit on Food Fortification last month called for major effort to improve oversight of food fortification programs in its Arusha Statement on Food Fortification.
Fortification with iron works when it is practiced using the correct standards and monitored to ensure compliance. For example in Costa Rica, foods were fortified as mandated, and anaemia was reduced as a result. Countries already fortifying flour or planning to start should also check that they are using the WHO-recommended standards for iron.
Ensuring programs are effective should be a top priority for donors, policy-makers, and programme implementers. While there has been tremendous progress in fortification, there is still work to be done.
For more guidance on flour fortification, visit Food Fortification Initiative and Gain.
Content on this page is paid for and provided by GAIN, a sponsor of the Guardian Global Development Professionals Network.
