Section 1:

Introduction

Why Fortify?

Overview of Fortification Process

Fortification’s Public Health Impact

Minerals and Vitamins Used in Flour Fortification

Why Fortify?

Health and Economic Benefits

• Prevent iron deficiency, neural tube birth defects, and other health concerns

• Improve the national economy by increasing productivity and decreasing healthcare expenditures

FFI photo

Why Fortify?Leverage Existing Infrastructure to Reach Population

Siemer flour millhttp://www.siemermilling.com/Locations/125/a/159

Overview: Wheat’s Natural Iron

• Bran contains 55% of wheat’s natural iron

• Germ contains 5% of wheat’s natural iron

The bran and germ are primarily used for animal feed.

Percentages calculated from USDA Nutritional Database

Image courtesy of the Wheat Foods Council

Bran

Germ

Endosperm

Wheat’s Mineral Loss in MillingMineral loss at 75-80% extraction

Overview: Wheat’s Natural Vitamins

Bran

Germ

Endosperm

VitaminFound in Bran (%)

Found in Germ (%)

Folic Acid (B9) 33 12

Niacin (B3) 86 2

Thiamine (B1) 33 64

Riboflavin (B2) 42 26

Pyridoxine (B6) 73 21

Pantothenic Acid (B5) 50 7

Percentages calculated from USDA Nutritional Database

Image courtesy of the Wheat Foods Council

Wheat’s Vitamin Loss in MillingVitamin loss at 75-80% extraction

Overview: Fortification ProcessPowdered vitamins and minerals are added to flour during the milling process using equipment called feeders.

A large mill may use a “feeder bank” such as this set of four. One feeder is for fortification and three are for other flour improvers.Photo courtesy of Research Products Company

Smaller mills may use a single feeder for fortification.Photo copyright: David Snyder / CDC Foundation 

Impact on Health: Iron

Burden of Deficiency

• Reduced productivity• Iron deficiency anemia• Undeveloped mental

capacity• Maternal mortality• Pre-term births

Health Benefits

• Increased productivity• Fully developed mental

skills• Improved maternal and

child health

“Iron deficiency affects more people than any other condition, constituting a public health condition of epidemic proportions.”

-World Health Organizationhttp://www.who.int/nutrition/topics/ida/en/

Success of Fortifying with Iron

Four studies of the effectiveness of fortifying with iron all showed improvement in iron status:

Country Population studied

China Women

Iran Women and men

Venezuela School-age children

Fiji Women

FFI review December 2012. Photo from istockphoto.com

Results of Insufficient Folic Acid (vitamin B9)

• Children born with neural tube birth defects (NTDs) such as spina bifida

• Permanently disabling or fatal

• More than 300,000 NTDs occur every year globally*

* Global Report on Birth Defects, March of Dimes Birth Defects Foundation, 2006

Photo of child with spina bifida from Google images

Impact of Fortifying with Folic Acid

• Reduce risk of NTDs 31% to 78%

• Healthcare savings from averted surgeries and therapy

• Cost: benefit ratios reported when spina bifida is prevented:o 1:12 in Chile

o 1:30 in South Africa

o 1:48 in the United States Photo from istockphoto

Risk reduction from Blencowe, H: Folic acid to reduce neonatal mortality form neural tube disorders. International Journal of Epidemiology. April 2010 (suppl_1):i110-i121Cost benefit data from:Llanos, A., et. al., Cost-effectiveness of a Folic Acid Fortification Program in Chile. Health Policy 83 2007:295-303.Sayed, A., et.al., Decline in the Prevalence of Neural Tube Defects Following Folic Acid Fortifcation and Its Cost-Benefit in South Africa. Birth Defects Research 82 2008:211-216.Grosse, Scott, et. al., Reevaluating the Benefits of Folic Acid Fortification in the United States: Economic Analysis, Regulation, and Public Health. American Journal of Public Health 95 2005:1917-1922.

Minerals and VitaminsUsed in Flour Fortification

Minerals Vitamins

• Iron• Zinc

• Folic Acid (B9)• Thiamine (B1)• Riboflavin (B2)• Niacin (B3)• B12• Vitamin A• Vitamin D

Types of Iron Used In Fortification

Elemental Iron(reduced iron or electrolytic iron)

Ferrous Sulfate

Ferrous Fumarate Sodium Iron EDTA (NaFeEDTA)

Factors for Choosing Iron Compound• Bioavailability (absorption)

– Water soluble compounds have the highest relative bioavailability because they are very soluble in gastric juices.

– The size, shape and surface area of the iron particle affects bioavailability, as does composition of food made with fortified flour.

• Sensory changes– High levels of some iron compounds could cause coloration or

rancidity of the flour.• Cost:

– Highly bioavailable forms of iron are more expensive, but less is needed per metric ton of flour for fortification to have a health impact.

• Magnets:– Iron salts (ferrous sulfate, ferrous fumarate and iron EDTA) will not

be attracted to magnets that may be used in milling process

Other Minerals in Flour FortificationZinc

• Zinc oxide is most commonly used

• Inexpensive• No sensory concerns• Use higher levels in high-

extraction flours due to higher phytic acid content

Calcium

• Calcium sulfate and calcium carbonate are both used

• No sensory concerns• Not included in premix

with other nutrients because levels are far higher than other nutrient additions

• Not usually included in fortification standards

B Vitamins in Flour Fortification

Folic Acid (B9)

• Folic acid is preferred source

• No sensory concerns• Relatively stable with

some loss from exposure to light and food preparation

• More bioavailable than B9 in natural food sources

Thiamine (B1)

• Thiamine mononitrate is preferred source

• No sensory concerns• Susceptible to losses

from exposure to light and heat and alkaline conditions (pH over 7)

B Vitamins in Flour Fortification

Riboflavin (B2)

• Orange crystalline powder

• Use only food grade material exceeding 97% purity

• Unstable in light

Niacin (B3)• Commonly used source:

nicotinic acid (commonly just called niacin) and nicotinamide.

• No sensory concerns• Nicotinic acid can cause

reddening in the skin on exposure

• Both niacin compounds are very stable in heat and light

B Vitamins in Flour FortificationPyrodoxine (B6)

• Pyrodoxine hydrochloride is preferred source

• No sensory concerns

• Stable to heat, but sensitive to UV light.

Cobalamin (B12)

• Cyanocobalamin is common source

• No sensory concerns• Relatively stable in heat, but

unstable in alkali and strong acidic environments

• Difficult and expensive to test for the small amounts used in fortification

• More bioavailable than B12 in natural food sources

Other Vitamins in Flour Fortification

Vitamin A•Retinyl acetate and retinyl palmitate are recommended.•Beta-carotene’s yellow color makes it undesirable for flour.•Available in encapsulated forms that do not cause sensory concerns•Significant losses can occur on storage if the encapsulation and antioxidant protection system is poor. A standard stability test at 45°C on the raw material should show losses no greater than 20% after 21 days.•Countries often fortify edible oil or sugar rather than flour with vitamin A

Other Vitamins in Flour Fortification

Vitamin D•Form used in fortification: D3 Cholecalciferol•Countries often fortify dairy products with vitamin D in combination with vitamin A•Currently only a few countries fortify flour with vitamin D

More Information

• Health, productivity and economic benefits of flour fortification: http://www.ffinetwork.org/why_fortify/index.html

• World Health Organization recommendations for wheat and maize flour fortification: http://www.who.int/nutrition/publications/micronutrients/wheat_maize_fortification/en/