In 1995, JavaScript was introduced as a computer programming language, DVDs were announced for media storage, Microsoft launched Windows 95 and 33 percent of non-pregnant women ages 15 to 49 years old worldwide had anemia.

1. Digital Re-print -
May | June 2014
Global leaders hoping to fight anemia with rice
fortification
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3. I
n 1995, JavaScript was introduced as a
computer programming language, DVDs
were announced for media storage,
Microsoft launched Windows 95 and 33
percent of non-pregnant women ages 15 to
49 years old worldwide had anemia.
Computer technology has made tremen-
dous strides since 1995, but by 2011, the
global percent of non-pregnant women with
anemia had only dropped to 29 percent, as
published in The Lancet Global Health in
July 2013.
Global leaders in grain fortification are
hoping that the technology for rice fortifica-
tion will soon match the pace of computer
technology development and lead to more
success at preventing nutritional anemia.
“People around the world get most
of their calories and carbohydrates from
foods made with wheat, maize or rice. To
the extent that we can fortify them, the
greater health impact we will have,” said
Reynaldo Martorell, Woodruff Professor of
International Nutrition and Senior Advisor
at the Global Health Institute at Emory
University in Atlanta, GA, USA.
Martorell is also a member of the
Flour Fortification Initiative (FFI) Executive
Management Team.
Adding minerals and vitamins
during the process
The type of fortification Martorell refers
to is adding vitamins and minerals during the
industrial milling process so that consumers
will have more nutrients in their staple foods.
Flour is commonly fortified to prevent
nutritional anemia and neural tube birth
defects such as spina bifida. Rice fortification
presents a largely untapped opportunity.
Since beginning in 2002, FFI has focused
on industrially milled wheat flour with some
efforts in maize fortification. The work is
expanding to include fortification of industri-
ally milled rice because it has the poten-
tial to affect billions of people, said Scott
Montgomery, FFI Director.
The highest concentrations of people
with anemia, and countries with some of the
highest estimates of pregnancies affected by
neural tube defects, are in south Asia and
West Africa. In these areas, rice is often
the most commonly consumed cereal grain.
Consequently several international groups
are accelerating efforts to fortify rice.
The World Food Programme, for exam-
ple, regularly includes fortified rice in its
food distribution programs. The international
non-profit groups PATH, the Global Alliance
for Improved Nutrition (GAIN), and the
Micronutrient Initiative are also working on
projects related to rice fortification.
The 2011 percentage of non-pregnant
women worldwide with anemia represents
528 million women.
For comparison, that is more than eight
times the total population of the United
Kingdom. Anemia leads to fatigue which
lowers productivity. It limits a child’s ability to
learn and the child never regains that mental
capacity. Anemia can even cause maternal
deaths.
Three technologies
Anemia can be caused by multiple factors
such as chronic infections and parasites, but
a common cause is deficiency in iron and
other nutrients.
In the United States, for example, add-
ing folic acid to enriched grains has virtually
eliminated anemia caused by vitamin B9 defi-
ciency in older adults.
Fortifying with folic acid, a form of vitamin
B9, has also been estimated to prevent
38,417 neural tube birth defects in one year,
for an average of 105 healthier babies a day.
Three primary technologies are used to
fortify rice: extrusion, coating, and dusting.
Extrusion involves making dough from rice
flour and nutrients then putting the dough
through an extruder to make rice-shaped
kernels. This can be done at various tem-
peratures.
Coating requires spraying rice with a mix
of vitamins and minerals plus ingredients
such as waxes and gums that help the nutri-
ents adhere to the rice. The fortified kernels
are then blended with unfortified rice, usually
at ratios between 1:50 and 1:200.
Rice is sometimes fortified by dusting it
with a powdery mix of vitamins and miner-
als. Dusting is not appropriate in cultures
where rice is rinsed or cooked in water that
is discarded as these steps will wash off the
added nutrients.
Extruded or coated rice kernels are
considered premix, and this must be identi-
cal to unfortified rice. In many cultures, rice
preparation includes picking out kernels that
do not conform in color, shape, or texture.
Consequently, for fortified rice to be effec-
Global leaders hoping to fight anemia
with rice fortification
by Sarah Zimmerman, Communications Coordinator, Food Fortification Initiative
(formerly the Flour Fortification Initiative)
Table 1 – Top 25 countries in rice available per
capita
Country
Rice
Available
(grams per
person per
day)
Population
(in
thousands)
Bangladesh 475 147,030
Lao People's
Democratic Republic
454 6,112
Cambodia 439 13,978
Viet Nam 387 86,901
Myanmar 386 47,601
Thailand 365 68,706
Indonesia 349 237,414
Philippines 338 91,703
Guinea 290 9,761
Madagascar 289 20,124
Sri Lanka 284 20,669
Guinea-Bissau 271 1,484
Liberia 263 3,836
Sierra Leone 253 5,739
Guyana 224 753
Korea, Republic of 223 47,964
Nepal 218 29,433
Brunei Darussalam 211 392
Korea, Democratic
People's Republic
209 24,238
China 209 1,342,428
Malaysia 203 27,949
Senegal 196 12,107
Comoros 188 716
India 187 1,207,740
Suriname 186 520
Population total (in thousands) 3,455,298
Population figures from the United Nations
Population Division
Grain availability from the Food and Agriculture
Organization of the United Nations
These fortified rice kernels are made with a high concentration
of vitamins and minerals. They are blended with unfortified rice
then packaged for consumers. Buhler Group photo.
Fortification
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5. tive, the premix needs to meet the consum-
ers’ expectations for how rice should look,
taste, and smell.
FFI recently reviewed published litera-
ture about rice fortification. Ten studies in
controlled environments compared a vari-
ety of health outcomes between individuals
who received fortified rice and those who
received non-fortified rice.
These studies were conducted in the
Philippines, Brazil, Nepal, Mexico, India, and
Thailand, and typically used extrusion rice
technology. Rice was fortified with nutrients
including iron, folic acid, thiamin, niacin, vita-
min A, and vitamin B12. Some of the health
outcomes investigated included anemia, iron
deficiency, body iron stores, plasma ferritin,
and plasma retinol. The results included:
• Four of the eight studies that
investigated anemia found statistically
significant declines in anemia prevalence.
• Five of the six studies that investigated
iron deficiency observed statistically
significant reductions in the fortified rice
group.
• Two of two studies observed statistically
significant improvements in body iron
stores.
• Five of seven studies observed
statistically significant increases in plasma
ferritin.
• One of six studies observed statistically
significant increases in plasma retinol.
The challenge now is making rice for-
tification feasible for entire populations so
that more people have access to these
health benefits. Rice fortification is most
easily implemented in modern 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.
The cost of fortification
The cost of rice fortification varies greatly
based on the type of fortification technol-
ogy used, whether fortified rice is produced
locally or procured from another source, and
the ratio of premix blended with unfortified
rice.
A facility which produces rice premix may
need an initial capital investment of US$0.3
million, US$0.75, or US$4 million for coating,
cold extrusion or hot extrusion technology,
respectively. Alternatively, rice premix can
be ordered from another source then blend-
ed with unfortified rice. That option requires
the on-going costs of shipping fortified rice
from the premix plant to the blending facility.
On-going costs to fortify depend in part
on the number of nutrients included. Rice
fortification costs range from US$6 to US$20
per metric ton of rice fortified with iron, folic
acid, vitamin A, thiamine, niacin, vitamin B12,
and zinc. The cost range assumes the rice
premix is blended with unfortified rice at a
ratio of 1:100. At that ratio, the consumers'
price increase is estimated to be between
2% to 5% of the current retail price.
Rice fortification is considered economi-
cally feasible if the population consumes at
least 100 grams per capita per day. The 25
countries with the highest amounts of rice
available for human consumption, according
to Food and Agriculture Organization of the
United Nations, have a combined population
of 3.4 billion (See Table 1). Yet of these,
only the Philippines has mandatory rice
fortification. Other countries with legislation
to require rice fortification are Costa Rica,
Nicaragua, Panama, and Papua New Guinea.
Like any new intervention, rice forti-
fication faces multiple challenges before
it reaches large-scale implementation. The
potential health impact justifies continuing
efforts to make rice fortification feasible.
More inforMation
FFI
Website: http://www.ffinetwork.org/
about/faq/faq_rice_industry.html
About the author:
Sarah Zimmerman is the
Communications Coordinator for the
Flour Fortification Initiative (FFI) which
offers advocacy and technical support
to countries as they plan, imple-
ment, and monitor grain fortification
programs. With a bachelor’s degree
in journalism, Sarah wrote stories for
daily newspapers and marketing pieces
for private-sector organizations before
joining FFI in 2008.
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