Fortifying flour is a great public health success s tory. Millers add vitamins and minerals to their products, and consumers increase their nutrient intake while eating foods they enjoy. In turn, the population greatly reduces its risk of debilitating anemia from nutritional deficiencies and devas tating birth defects from insufficient folic acid.

1. S
uccess is only achieved if flour fortification
is well implemented and monitored.
Unfortunately these two criteria are not
always met. A study published in 2015
estimated that less than half the samples
from 20 national food fortification
programs in 12 countries met the country’s
fortification standard for the relevant staple
food.
Food inspectors are typically in charge of monitoring flour
mills, according to Guidelines on Food Fortification with
Micronutrients published by the World Health Organization
(WHO) and the Food and Agriculture Organization of the United
Nations. At the same time, flour millers are responsible for
quality implementation.
The Food Fortification Initiative (FFI) offers the following
suggestions for flour millers to be sure that their products are
adequately and consistently fortified. Following these steps will
help ensure that fortification meets the public health expectations:
Premix Procurement: Choose reputable premix manufacturers
which use high-quality nutrients. The Global Alliance for
Improved Nutrition (GAIN) maintains a list of premix suppliers
that meet quality requirements (www.gainhealth.org).
Premix Receiving: When premix is delivered, inspect the box to
be sure the content has not been damaged in shipment. Confirm
that the nutrient content indicated on the certificate of analysis
matches what was ordered.
Premix Storage: Keep premix away from sunlight, excessive
heat and humidity, and potential water damage.
Premix Supply: Use the oldest premix first. Also, regularly
compare the amount of premix used to the rate of flour produced.
Unusual increases or decreases in the amount of premix used
indicate problems in fortification procedures.
Feed Rate: Check the premix feeder or dosifier hourly and refill
it as needed. Also, weigh the amount of premix discharged by
the feeder over one to two minutes then compare the result to the
weight of premix expected to be discharged over that period. Do
this at least once in every eight-hour shift.
Iron Spot Test: Conduct this simple, rapid test to indicate
qualitatively whether iron has been added to the flour. The
test involves adding a solution of hydrochloric acid, hydrogen
peroxide, and potassium thiocyanate to a flour sample. In a few
minutes, dark spots will appear if the flour has been fortified with
iron. The presence of iron in fortified flour is considered a proxy
Fortifying flour is a great public
health success story. Millers add
vitamins and minerals to their
products, and consumers increase
their nutrient intake while eating
foods they enjoy. In turn, the
population greatly reduces its
risk of debilitating anemia from
nutritional deficiencies and devas
tating birth defects from insufficient
folic acid.
Millers essential
to public health
success story
42 | February 2016 - Milling and Grain
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2. for other nutrients that were included in the premix. The iron
spot test is formally Method 40-40.01: Iron Qualitative Method
as approved by the American Association of Cereal Chemists
(AACC).
The spot test works well for ferrous sulfate, ferrous fumarate, and
electrolytic iron. When flour is fortified with sodium iron EDTA
(NaFeEDTA), the test works when hydrogen peroxide is not used
as a reagent.
Outside Testing: Periodically send fortified flour samples to
laboratories to be sure that all the specified nutrients are present
in the correct amounts. This requires sophisticated equipment and
careful adherence to protocols because the level of vitamins and
minerals is very small compared to the volume of flour. Some
milling associations or large milling companies have centralized
laboratories for this work.
Keeping accurate records of these procedures will be useful
when regulatory authorities audit the mill for compliance with
the national fortification standard. More importantly for public
health, these steps will give millers confidence that they are
investing in the well-being of their families, their staff, and their
customers.
Wheat and maize flours are commonly fortified with iron to
prevent anemia from iron deficiency. When asked what it felt
like to have anemia, people compared it to walking in quicksand
and having constant jet lag. In addition, iron deficiency limits
a child’s cognitive development which affects future earning
potential, and it contributes to 20% of all maternal deaths.
Anemia from iron deficiency is not confined to lower-income
countries. Iron deficiency is “the most common and widespread
nutritional disorder in the world,” according to WHO. WHO
estimates that 42% of anemia in children, 49% of anemia
in non-pregnant women of child-bearing age, and 50% of
anemia in pregnant women ages 15-49 years is related to iron
deficiency. That translates to 114.7 million children, 243.2 million
non-pregnant women of child-bearing age, and 16.2 million
pregnant women with anemia from iron deficiency.
Imagine that each non-pregnant woman with anemia is 1.65
meters tall. Now imagine all these women standing head to toe –
they would be able to reach the moon and circle it.
Whether fortification was effective against this widespread
health problem was the subject of two studies published in 2015.
One study published in July showed that countries which fortify
wheat flour alone or in combination with maize flour show a
2.4% decrease in anemia each year. A second study published
in October provided little evidence that fortification improved
anemia prevalence. The difference was that most countries in the
first study followed WHO recommendations for fortifying flour
with iron; most evaluations in the second study did not.
The WHO recommendations are based on the type of flour
and the amount of flour that is available daily for human
consumption. The recommendations take into account issues of
sensory changes from fortification and bioavailability of various
iron compounds. As the two studies illustrated, following the
recommendations is more likely to have a health impact than
fortifying with an iron compound that is not easily absorbed or
using too little iron.
Only four iron compounds are included in WHO
recommendations for wheat and maize flour fortification: ferrous
fumarate, ferrous sulfate, sodium iron EDTA, and electrolytic
iron. Sodium iron EDTA is the only compound recommended
for use in flour with an extraction rate greater than 80%. The
phytate content of such high extraction flour is likely to inhibit
the absorption of other iron compounds. Also, electrolytic iron
is only recommended where at least 150 grams of flour per
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3. person per day are available for human consumption. If wheat
flour availability is lower than that, the amount of electrolytic
iron needed for the desired health impact might cause sensory
problems in the flour.
Another nutrient commonly added to flour is folic acid, which
is a form of vitamin B9. Everyone needs this nutrient for cell
reproduction. Women who may become pregnant especially need
folic acid to reduce the risk of neural tube defects (NTDs). These
birth defects include spina bifida which causes permanent loss of
sensation and varying degrees of paralysis. Another NTD called
anencephaly is the result of a malformed brain, and it is always
fatal. A rare NTD is encephalocele in which part of the brain
protrudes through the skull.
The neural tube forms within the first few weeks after
conception, and women may not realize they are pregnant during
this time. If they wait until the pregnancy is confirmed to take
folic acid supplements, it may be too late for folic acid to have
its protective effect. Adding folic acid to flour, on the other hand,
helps ensure that women have enough folic acid as they enter the
pregnancy and throughout the critical first few weeks.
Every country that studied its birth defect prevalence showed a
decline in NTDs after fortification. One analysis showed that the
average drop in NTD birth prevalence after fortification was 46%.
The most recent example is from Brazil which recorded a 30%
decline in NTDs after fortification.
Another benefit to preventing NTDs is healthcare savings.
People with spina bifida can lead productive lives, but they may
need a lifetime of surgeries and treatments. Some countries have
compared the cost of fortification with healthcare expenditures
averted when spina bifida is prevented. The cost:benefit ratios
reported were 1:12 in Chile and 1:30 in South Africa. A recent
study in the United States showed that the cost savings were US$
603 million more than the cost of fortification.
Currently 79 countries have national mandates that require
fortifying wheat flour, maize flour, and/or rice with folic acid.
Yet less than 30% of the world’s industrially milled wheat flour
is fortified, according to FFI. About 48% of industrially milled
maize flour is fortified, but the proportion of maize flour that is
industrially milled is low. Less than 1% of industrially milled rice
is fortified.
In addition to the actions listed above for internal quality
control, millers can take several steps to make progress with
flour fortification. First, if your country already has legislation to
fortify flour, compare the standard with WHO recommendations
which are available in six languages.
See table one for recommended levels of five nutrients based
on the amount of wheat flour that is available for human
consumption. Notice that the iron and zinc recommendations are
different for high and low extraction flours. The estimates are
also based on grain availability. Those estimates from the Food
and Agriculture Organization of the United Nations are on the
country profiles on the FFI website.
Countries may want to include nutrients that are not in
the WHO recommendations in their fortifition standards.
For example, many countries include the B vitamins niacin,
riboflavin, and thiamin in flour fortification. On the other hand,
many countries do not include vitamin A in flour fortification
even though it is included in the WHO recommendations
because they fortify adequately fortify cooking oil or sugar with
vitamin A. Contact FFI at info@ffinetwork.org for assistance in
developing an appropriate flour fortification standard.
If your country does not have a fortification mandate, participate in
a National Fortification Alliance to promote fortification. Information
from the milling industry will help ensure that a country develops
standards that are feasible to implement. Contact FFI at info@
ffinetwork.org to find out if your country has a National Fortification
Alliance or other group advocating for fortification.
For more information on internal quality control and fortifying
flour to prevent nutritional anemia and neural tube birth defects,
see the FFI website.
www.ffinetwork.org
Image courtesy of the
© US Centers for Disease
Control and Prevention
(CDC)
Iron spot test - The red dots in the flour sample indicate that the
flour has been fortified with iron, and that is considered a proxy
for the other nutrients that were in the premix.
Photo courtesy of ©FFI.
Assuming each woman is 1.6 meters tall; each female figure
above represtents 15 million women.
Number of women of reproductive age with anemia reported
in The Global Prevalence of Anemia in 2011, published by World
Health Organisation in 2015. Photo from NASA Earth Observatory
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