1. Section 1: Introduction Why Fortify? Overview of Fortification Process Fortification’s Public Health Impact Minerals and Vitamins Used in Flour Fortification

2. 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

3. Why Fortify? Leverage Existing Infrastructure to Reach Population Foods made with wheat and maize are widely consumed Grain milling is a centralized business with broad distribution of products Consequently, fortification has the potential to reach millions of people. Siemer flour mill http://www.siemermilling.com/Locations/125/a/159

4. 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

5. Wheat’s Mineral Loss in Milling Mineral loss at 75-80% extraction

6. Overview: Wheat’s Natural Vitamins Bran Germ Endosperm Vitamin Found in Bran (%) Found in Germ (%) Folic Acid (B9) 3312 Niacin (B3) 862 Thiamine (B1) 3364 Riboflavin (B2) 4226 Pyridoxine (B6) 7321 Pantothenic Acid (B5)507 Percentages calculated from USDA Nutritional Database Image courtesy of the Wheat Foods Council

7. Wheat’s Vitamin Loss in Milling Vitamin loss at 75-80% extraction

8. Overview: Fortification Process Powdered 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

9. 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 Organization http://www.who.int/nutrition/topics/ida/en/

10. Success of Fortifying with Iron Four studies of the effectiveness of fortifying with iron all showed improvement in iron status: CountryPopulation studied ChinaWomen IranWomen and men VenezuelaSchool-age children FijiWomen FFI review December 2012. Photo from istockphoto.com

11. 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, 2006Dimes Photo of child with spina bifida from Google images

12. 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-i121 Cost 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.

13. Minerals and Vitamins Used in Flour Fortification MineralsVitamins Iron Zinc Folic Acid (B9) Thiamine (B1) Riboflavin (B2) Niacin (B3) B12 Vitamin A Vitamin D

14. Types of Iron Used In Fortification Elemental Iron (reduced iron or electrolytic iron) Ferrous Sulfate Ferrous FumarateSodium Iron EDTA (NaFeEDTA)

15. 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

16. Other Minerals in Flour Fortification Zinc 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

17. 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)

18. 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

19. B Vitamins in Flour Fortification Pyrodoxine (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

20. 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

21. 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

22. More Information Health, productivity and economic benefits of flour fortification: http://www.ffinetwork.org/why_fortify/index.html 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/ http://www.who.int/nutrition/publications/micronutrients/wheat_maize _fortification/en/