In 2002 when FFI began, 46 countries had mandates to fortify wheat flour, and 18 percent of the world’s industrially milled wheat flour was fortified with at least iron and folic acid. By 2018, 86 countries had legislation to fortify industrially milled wheat flour, and 31 percent of the worlds’ industrially milled flour was fortified. While this is progress, more work needs to be done to fortify the global supply of industrially milled wheat flour.
Communications Coordinator for the Food Fortification Initiative
By the year 2030, the United Nations (UN) would like to end poverty, protect the planet, and ensure prosperity for all. To do this, in 2015 the UN adopted a set of 17 “Sustainable Development Goals,” each with specific targets to be achieved over 15 years.The UN probably did not have bakers in mind when it created these ambitious aims, even though fortified flour could contribute toward the nine of the goals. Wheat flour has been fortified since 1942 in some countries, but currently only 31 percent of the world’s industrially milled wheat flour is fortified, according to estimates from the Food Fortification Initiative (FFI).
Using fortified flour has virtually no consequences for bakers. Internationally accepted guidelines outline types and amounts of nutrients to use in fortification without causing changes to the food’s sensory qualities. This has been tested in Africa and Asia, including shelf life studies with instant noodles that were made with fortified wheat flour. Bakers can use fortified flour without reformulating their products. The nutrients used are essential to human health; they are not contaminants or allergens that require cleaning the production lines after their use.
One reason fortified flour has a great potential for impacting human health is that so many people eat flour-based foods. Consider pasta as an example. The United States leads the world in pasta consumption at 2.7 million tons a year, according to the International Pasta Organization. Italy is second at 1.5 million tonnes. But the population of the United States is more than five times the population of Italy. On a per capita basis, Italy is the global leader in pasta consumption at 25.3 kilograms per year; Tunisia is second at 16 kilograms. About 14 million tons of pasta are produced annually worldwide, according to the 2013 World Pasta Industry Status Report from the International Pasta Organization. Yet only half of the countries that produce more than 300,000 tonnes of pasta each year any of their wheat flour (Table 1).
Flour Fortification and the Sustainable Development Goals
Meeting the 17 Sustainable Development Goals (SDG) will require multiple strategies. Adding vitamins and minerals to flour contributes toward progress of some SDGs by improving cognitive development, maternal health, and productivity.
SDG Goal No. 1 - No poverty
Anemia occurs when the body lacks hemoglobin which carries oxygen from the lungs throughout the body. Anemia has many causes. The World Health Organization (WHO) estimates that 42 percent of anemia in children and 50 percent of anemia in women is related to iron deficiency. Folic acid, zinc, riboflavin, vitamin B12, and vitamin A deficiencies can also cause anemia. Vitamin A is more often added to cooking oil, margarine, or sugar, but the other nutrients can all be included in fortified flour.
People who have had anemia say it is like being a zombie, walking in quick sand, or having jet lag all the time. Consequently, anemia reduces an individual’s work capacity, and a high prevalence of anemia among a population reduces the gross domestic product.
Anemia is estimated to contribute to 17 percent lower productivity in heavy manual labor and 5 percent lower productivity in other manual labor. Additionally, children who are iron deficient do not develop their full mental capacity. This means iron deficiency in childhood affects individual’s academic performance and future earnings potential. Consequently, childhood anemia is associated with a 2.5 percent drop in wages in adulthood, affecting productivity and economic growth and contributing to poverty.
SDG Goal No. 2 - Zero hunger
Part of this goal is to end all forms of malnutrition. Globally, 45 percent of deaths of children under 5 years of age are attributed to malnutrition.
This SDG specifically mentions stunting and wasting in children. Stunting is when children are more than two standard deviations below the expected height for their age. Poor nutrition, repeated infections, and inadequate psycho-social stimulation can cause it. Wasting is when children’s weight is too low for their height. It is usually from a lack of food or from an infectious disease such as diarrhea. WHO estimates that 155 million children under 5 years of age are stunted, and 52 million children are wasted. Another 17 million children in this age group are considered severely wasted. Fortifying flour used to make biscuits or pasta that children often eat, such as Pastina, is one step toward preventing stunting and wasting and reaching this Sustainable Development Goal.
SDG No. 3 - Good health and well-being
This goal is split into sections including maternal and newborn health, infectious disease, and non-communicable diseases. Fortification helps to reach the goals in each of these categories.
Maternal and Newborn Health
Fortifying with folic acid greatly reduces women’s risk of having a pregnancy affected by a birth defect of the brain or spine. These birth defects develop within 28 days after conception. Women often do not realize they are pregnant during this time, and if they have not been planning a pregnancy, they are not likely to be taking folic acid supplements. But fortification increases folic acid intake as people eat their favorite foods. One meta-analysis showed that fortifying wheat flour with folic acid reduced the incidence of these severe birth defects by an average of 46 percent.
Anemia during pregnancy increases the risk of death for the mother. Adding iron, riboflavin, folic acid, zinc, vitamin B12, and vitamin A to food during the milling process helps reduce the risk of anemia from nutritional deficiencies. Pregnant women who are anemic also have a higher risk of having a child with low birth weight, meaning less than 2500 grams or 5.5 pounds, according to WHO. Newborns that small are prone to death and diseases while they are young. If they survive, they are more at risk for poor mental development in childhood and chronic health problems such as diabetes and heart disease later in life.
Infectious and Non-Communicable Diseases
Zinc is a mineral that promotes immunity, resistance to infection, and proper growth and development of the nervous system, and is integral to healthy pregnancy outcomes. Zinc deficiencies increase risk of malaria, pneumonia, diarrhea. Zinc is included in WHO recommendations for fortifying wheat flour. While people only need small amounts of zinc, WHO estimates that “worldwide, zinc deficiency is responsible for approximately 16 percent of lower respiratory tract infections, 18 percent of malaria and 10 percent of diarrhoeal disease.”
A study published in The Lancet Infectious Diseases in June 2017 noted that diarrhea remains a leading cause of death globally. The study estimated that 1.31 million people died from diarrhea in 2015, including 499,000 children under age 5. While unsafe water and unsafe sanitation remain the leading risk factors, vitamin A and zinc deficiencies contribute to diarrhea.
Red meat, poultry, and seafood are good sources of zinc. This means that vegetarians and people who cannot afford to purchase meat are at higher risk of zinc deficiency. In addition, the human body has no mechanism to store zinc, so a daily supply is needed. To increase the population’s zinc intake, 34 countries include zinc in their standards for wheat flour, maize flour, and/or rice fortification, according to FFI.
SDG No. 4 - Quality education
Poor health in childhood leads to reduced educational achievement. A large body of literature documents that iron deficiency causes cognitive deficits and developmental delays. On the other hand, children who have adequate iron intake have more energy to participate in classroom exercises, and they are more mentally prepared to master the material. Fortifying flour used to make foods commonly eaten by school-age children is one way to help students maximize their educational experiences.
SDG No. 5 - Gender equality
Anaemia rates in females are much higher than males. While anaemia rates from iron deficiency decrease for males by the end of puberty, they remain high for females through reproductive years due to menstruation. Therefore, reducing anaemia by fortifying with iron helps equalize girls’ academic performance with boys and boosts women’s worker productivity to help achieve gender equality.
SDG No. 8 - Decent work and economic growth
Economic growth is stymied when the population’s nutritional needs are not met. In a review of the World Bank report title “An Investment Framework for Nutrition,” consultant Julia Dayton Eberwein noted that every dollar invested in nutrition-specific interventions would yield between $4 and $35 in economic returns.
One example is averting healthcare expenditures by fortifying with folic acid to prevent brain and spine birth defects. Spina bifida is the most common of these birth defects; it cannot be cured, and it often leads to some level of paralysis and bowel and bladder control problems. Total lifetime costs for medical care, development services and indirect costs for patients with spina bifida in 2002 was US $620,484 per patient, according to one literature review.
SDG No. 10 - Reduced inequalities
Developing countries bear most of the world’s nutrient deficiencies. This increases the risk of death, illness, and susceptibility to poor health.Yet vitamin and mineral deficiencies are not limited to developing countries. The WHO notes that iron deficiency is “significantly prevalent” in industrialized countries. Birth defects of the brain and spine also occur in countries of every economic status. Fortifying flour with essential vitamins and minerals will reduce inequalities between and within countries.
SDG No. 11 - Sustainable cities
In 2014, 54 percent of the world’s population lived in urban areas, compared to 30 percent in 1950, according to the United Nations (UN) World Urbanization Prospects, 2014 Revision. The report estimates that by 2050, 66 percent of the world’s population will be urban.
Living in a city does not mean being affluent. This SDG notes that 880 million people lived in urban “slum-like conditions” in 2014. Urban residents are likely to benefit from fortification of industrially milled flour and rice. Consequently, fortification is an opportunity to improve the nutrient intake of a significant proportion of the population, including the urban poor who shop in informal markets. Improving the quality life of urban residents by increasing nutrient intake is one way to make cities more sustainable as improved nutrition has the benefits mentioned in the previously listed SDGs.
SDG No. 17 - Partnerships for the goals
Effective partnerships are essential for fortification because no one sector can be successful on its own. The nutrition community needs to be involved in setting appropriate standards for the type and amounts of nutrients to include in fortification. The government needs to include fair monitoring practices in its food safety program. The industry needs to make systematic changes to fortify its products routinely with quality nutrients.
FFI’s first recommendation to any country considering fortification is to form a national alliance. Seek participation and commitment from national leaders representing public, private, and civic sectors. Involving all sectors early in the process prevents overlooking key information. It also builds commitment from each group to work toward success.
In 2002 when FFI began, 46 countries had mandates to fortify wheat flour, and 18 percent of the world’s industrially milled wheat flour was fortified with at least iron and folic acid. By 2018, 86 countries had legislation to fortify industrially milled wheat flour, and 31 percent of the worlds’ industrially milled flour was fortified. While this is progress, more work needs to be done to fortify the global supply of industrially milled wheat flour. This will help make progress toward the Sustainable Development Goals, and more importantly, enable individuals to move closer toward reaching their full potential.