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India

Wheat Flour and Rice

With a high prevalence of anemia and preventable birth defects as well as high consumption of both wheat flour and rice, the potential health impact of fortifying cereal grains in India is immense.

Twenty-four Indian states report anemia prevalence of 26 to 65% among married women; the average is 50%. The World Health Organization considers anemia prevalence over 40% a severe public health concern as it causes debilitating fatigue, lowers productivity, and contributes to maternal deaths.

Anemia can be caused by many things, including deficiencies of iron and vitamins B9 (folic acid) and B12. The typical vegetarian diet in India provides very little iron and vitamin B12, which are most commonly found in animal-based food sources.

In India, 45 of every 10,000 births (live births and stillbirths) have a birth defect of the brain or spine. With 25.6 million annual births, this equates to 115,390 birth defects of the brain or spine every year. Adequate intake of vitamin B9 could lower the prevalence to 6 per 10,000 live births.

Spina bifida is an example of these birth defects. It has varying degrees of severity and can cause lifelong disability. Another example is anencephaly, which is always fatal. Of infants born with a birth defect of the brain or spine, 75% die before their fifth birthday.

Many vegetables include vitamin B9, but it is very difficult to reach the recommended daily intake of this essential vitamin from unfortified food alone.

At 190 grams per person per day, rice is the most widely available cereal grain in India according to the Food and Agriculture Organization of the United Nations. Wheat flour availability is 166 grams per person per day.

FFI has identified 18 states in India with potential for fortified rice or wheat flour in various market channels. Wheat flour fortification in the government’s Public Distribution System (PDS) has successfully moved forward in the state of Haryana. FFI has provided technical support in Haryana by conducting a wheat supply chain analysis, calculating the costs for the government to supply fortified wheat flour in the PDS system, and ensuring consumer acceptance of the fortified product.

For the remaining 17 states, FFI proposes examining the current political environment to determine which states have leadership willing to support grain fortification with at least iron, vitamin B12, and folic acid. For the identified states, FFI would conduct an assessment to include:

• Industry capacity to fortify flour and/or rice using published reports and interviews with millers

• Current wheat flour and rice consumption patterns based on existing survey data

• Potential distribution channels such as the PDS and open market, and the reach of each distribution channel

Next, FFI would present results of this assessment to state leaders and, building on the successful Haryana model, collaboratively develop practical, operational plans to fortify grains in each state. Activities would include:

• Promote mandatory fortification so that costs and health benefits are shared equally    

• Create awareness about nutritional deficiencies, their consequences, and benefits of fortification

• Generate commitment among influential multi-sector leaders to support fortification

• Train millers to fortify their wheat flour and rice according to national standards 

• Develop sustainable procedures for internal and external monitoring to ensure compliance with India’s fortification standards

• Share the strategy with other nutrition groups in India to avoid duplication of efforts

FFI’s vision is for mandatory, sustainable grain fortification to be implemented and monitored in all 18 states.

Photo: Arjun Claire EU/ECHO

Africa: The Final Sprint

Wheat Flour, Maize Flour, and Rice

To take large-scale fortification programming across the finish line in countries in Africa that have demonstrated high potential for impact and high feasibility for fortification, FFI proposes the "Final Sprint," a bold, focused approach that places individuals on the ground in selected countries. These individuals will serve to guide government, private sector, and civil society entities over a sustained four-year period through a process that ensures quality programs are put in place using innovative business models and sustainability plans that position each country with the ability to own, operate, and shape the program long into the future.

The Final Sprint will support 43 countries using a unique staffing and technical assistance model. For just over $13 million over four years, the approach will avert more than 21 million cases of anemia among women of reproductive age (WRA) and 43,000 debilitating neural tube defects (NTDs) in children per year by making quality fortified wheat flour, maize flour, and/or rice available to the most vulnerable through country-led fortification programs.

Based on work done under the Smarter Futures grant over the past 15 years and lessons learned around effective models of technical support undertaken by FFI in other regions of the world, FFI proposes replicating a model it uses in Egypt and India by placing one staff person in one or two countries (e.g., one staff person would be responsible for the country in which they were physically located in addition to one additional neighboring country based on stage of country program status). Instead of setting up permanent offices in each country, FFI proposes leveraging existing networks of partners and government to host staff and/or cost-share office space to ensure a nimble and efficient team.

Photo: Xaume Olleros/RTI

Africa

Wheat Flour and Maize Flour

Tremendous progress has been made across Africa in terms of wheat and maize flour fortification over the years; however, significant gaps still remain. This includes countries that have a demonstrated nutritional need and the presence of political will but do not yet have national programs in place. In addition, there are numerous countries that have programs in place but are struggling with effective implementation and adequate monitoring. Supporting these countries would ensure that an additional 86.7 million people across the African continent have access to adequately fortified grains.

Countries would include:

• Algeria (no current grain fortification program in place)

• Angola (no current grain fortification program in place)

• Botswana (no current fortification program in place)

• Mauritius (no current grain fortification program in place)

• Morocco (difficulties with implementation and monitoring)

• Mozambique (difficulties with implementation and monitoring)

• Namibia (no grain fortification fortification program in place)

• South Africa (difficulties with monitoring)

• Uganda (difficulties with monitoring)

• Zimbabwe (difficulties with implementation and monitoring)

FFI would:

• Collaborate with national leaders to secure buy-in for a comprehensive national grain fortification program.

• Support drafting of national standards that would identify the type and level of nutrients to be added to wheat flour and/or maize flour based on current consumption patterns and nutritional needs.

• Support millers and government inspectors in the scale-up for fortification.

• Support millers and government in the design of effective monitoring frameworks for the fortification program.

Photo: Rod Waddington

Africa: Egypt

Wheat Flour

During the COVID-19 pandemic, the uncertainty of supply chains, increased premix prices, and trade restrictions have led some countries to scale back efforts to fortify grains with vitamins and minerals that strengthen individual health and whole economies. Yet the Egyptian government’s commitment to the health of its citizens is clear: despite challenges posed by a pandemic, Egypt has partnered with FFI to restart the country’s wheat flour fortification program, which ended in 2014.

Malnutrition from micronutrient deficiencies is a pressing public health issue in Egypt: 20-30% of women are anemic, birth defects are three times what they could be if women had adequate intake of folic acid, and losses in gross domestic product due to vitamin and mineral deficiencies are over US $800 million annually.

But the potential for fortification to dramatically improve Egyptians’ nutritional status is even greater. Through an initial situation assessment, FFI found that, if the government enacts mandatory fortification for subsidized wheat flour as well as wheat flour sold on the open market, fortified wheat flour will reach 90% of the population (90 million people) providing a tremendous opportunity for Egypt to address persistent health and economic challenges.

FFI has also completed a comprehensive situation and mill assessment that found 80% of Egyptian mills have the readiness, technical capacity, and timeline to commence fortification of flour.

With additional funding, FFI would:

• Collaborate with public, private, and civic champions to secure buy-in for a comprehensive national fortification program.

• Support drafting of national standards.

• Support millers and government inspectors in the scale-up for fortification.

• Support millers and government in the design of effective monitoring frameworks for the fortification program.

Africa: Pull Strategy

Wheat Flour and Maize Flour

One of FFI’s innovative approaches to ensure high-quality fortified foods are available in Africa is a grassroots Pull Strategy that engages consumer associations and disability groups to become part of program performance monitoring. A complement to government-led “push” strategies, the Pull Strategy augments government monitoring to increase the volume of fortified staple foods that meet quality and nutrition standards. With pilot implementation projects in Malawi and Uganda in 2018-2019, FFI has provided local advocates with the technical assistance and coordination they need to encourage food producers to comply with fortification standards.

FFI proposes continued support in Malawi and Uganda as well as Kenya, Tanzania, and Zambia to:

• Conduct initial landscape analyses and market share size and value analyses.

• Support and train stakeholders to conduct a simple, sentinel-type market assessment and commercial monitoring of fortified foods.

• Coordinate analyses of sampled foods at national laboratories.

• Liaise with public, private, and civic stakeholders to create commercial monitoring report and media strategy.

• Support millers and government in the design of effective monitoring frameworks for the fortification program.

What are push and pull?

PUSH: Government legislation to require millers to fortify is a “push” or top-down approach to fortification. Though push is the most common approach, it may not lead to nationwide fortification compliance in certain countries.

PULL: Consumer demand to encourage millers to comply with standards is a “pull” or bottom-up approach to fortification.

Photo: iStock

West Africa

Rice

The highest per capita consumption of rice outside of Asia is in West Africa. Specifically, 12 West African countries present an opportunity to reach an additional 146 million people with fortified rice. These are countries in which there is limited volume of industrially milled domestic rice but high volumes of imported rice. Several countries in West Africa already fortify wheat flour, salt, and cooking oil. These countries understand why fortification is important and why mandatory fortification is necessary. Fortifying rice would fill a nutrition gap not being addressed by existing programs. However, several countries would need to collectively mandate rice fortification to make it economically feasible.

FFI’s proposed activities and milestones would occur in three phases over three years:

Photo: Staton Winter/UN

Asia-Pacific: Bangladesh

Wheat Flour

The burden of micronutrient deficiencies on women and children in Bangladesh is staggering. The World Health Organization considers the level of anemia in women of reproductive age and pre-school aged children, which is over 40% of both demographic groups, a serious public health problem. Severe anemia, which is often caused by iron deficiency, can lead to maternal death and stunted childhood cognitive development. Furthermore, for every 10,000 babies born in Bangladesh, 47 are born with a neural tube defect—nearly eight times the number of neural tube defects that occur in countries with mandatory, effective folic acid fortification. This means that out of 2.9 million births in 2018, 13,795 Bangladeshi babies were born with a neural tube defect.

In 2019, the Bangladesh Government requested FFI’s assistance to strengthen its fortification program. FFI explored the feasibility of fortifying wheat flour and rice and found that both food vehicles would reach the same population. However, FFI also found that the country’s wheat flour milling industry is more consolidated, meaning it has a smaller number of large mills, than the rice milling industry and could more feasibly adopt fortification while also reaching the same population. As a result, wheat flour fortification provides the best opportunity for strengthening nutrition in Bangladesh, potentially reaching 59 million people, and preventing 9,260 neural tube defects.

Bangladesh already has legislation and standards in place for mandatory oil and salt fortification. Unlike fortified oil and salt, however, fortified wheat flour can deliver larger and more varied amounts of essential micronutrients (including iron and folic acid), making it an ideal food vehicle to build a smarter, stronger, and healthier future.

With additional support, FFI could:

• Collaborate with national leaders to secure buy-in for a comprehensive national wheat flour fortification program.

• Review existing national standards and provide recommendations for amendments based on current consumption patterns and nutritional needs.

• Provide technical support to national laboratories to develop protocols and testing validation for analysis of wheat flour.

• Provide training and technical support to millers and government inspectors to plan, implement, and monitor the scale-up of mandatory wheat flour fortification.

Asia-Pacific: China

Wheat Flour and Rice

Certain provinces in China have some of the highest observed rates of birth defects of the brain and spine in the world. Though several studies have demonstrated that fortified wheat flour improves nutrient status in Chinese communities, the government has yet to make wheat flour fortification part of its national nutrition program. Some businesses in China voluntarily fortify products, but this has not led to a widespread health impact.

In China, 212 grams of rice are available for human consumption per person per day, followed closely by wheat flour at 173 grams per person per day according to the Food and Agriculture Organization of the United Nations. Fortified rice, to FFI’s knowledge, has not yet been discussed in China. FFI’s five-year action plan is in three stages:

Asia-Pacific: Mongolia

Wheat Flour

FFI support to partners in Mongolia in 2017 and 2018 resulted in the country passing a law on fortified foods in May 2018. FFI is eager to continue to provide support to Mongolia as it introduces supporting regulations and standards to implement its mandatory fortification program.

With additional support, FFI would:

• Train mill staff to set up equipment and to implement and monitor fortification.

• Guide regulatory authorities to practice a sustainable monitoring program.

Photo: Ray Witlin

Asia-Pacific: Papua New Guinea

Wheat Flour and Rice

Key improvements to Papua New Guinea’s national mandate for rice fortification would increase the program’s nutritional benefits for consumers. The National Department of Health, UNICEF, and University of Papua New Guinea are engaged partners, but they lack technical expertise to improve the existing fortification program.

FFI would work with the National Department of Health to make the following changes:

• Specify the use of rinse-resistant kernels so that the nutrients are not removed when rice is washed before cooking.

• Include additional essential nutrients such as folic acid in fortified rice.

• Fortify wheat flour as well as rice.

• Support the legislative process to pass the proposed Food Act update and corresponding updates to Food Sanitation Regulations.

• Work closely with import food control agencies to improve efficiency and quality of the regulatory monitoring system, including integration of routine monitoring for fortified foods.

Photo: David Kirkland

Eastern Europe

Wheat Flour

Bread and pasta are commonly consumed across Eastern Europe and Central Asia, but very little wheat flour is fortified there. Several countries have worked toward wheat flour fortification in the past but have not finished the work. Advocacy is needed to complete the projects.

In Ukraine, Georgia, Kazakhstan, and Tajikistan, FFI would:

• Establish an online portal to report progress and future plans.

• Provide technical input into standards and regulatory frameworks of countries.

• Support capacity development on monitoring and surveillance.

• Continue advocacy and awareness creation for an enabling environment on food fortification.

Photo: Photo: Armine Grigoryan/World Bank

Europe: Ukraine

Wheat Flour

Micronutrient malnutrition and its debilitating health consequences are a serious public health problem in Ukraine. Of all European countries, Ukraine has the highest prevalence of birth defects of the brain or spine, which can be caused by a lack of folic acid during critical points before and during pregnancy. Ukraine also has the highest prevalence of child mortality associated with these birth defects.

Wheat flour is the most widely consumed staple food in Ukraine. Although flour fortified with folic acid and other micronutrients is produced and marketed in the country, uniform national standards and consumption across the population, particularly among those most vulnerable to micronutrient deficiency, are lacking.

In June 2021, the Ukrainian Parliament began efforts to mandate the fortification of wheat flour with folic acid. The draft was promptly adopted (Draft Law #5657), endorsed by a diverse group of deputies who represent various political parties and all regions of Ukraine, and sent for review by an appropriate committee in spring 2022.     

FFI proposes a 12-month project to assist in planning, implementing, and monitoring a robust fortification program and sustain present momentum for fortification within the Government of Ukraine. By so doing, FFI can help build a Ukrainian fortification program that saves lives and that other countries in the region could use as a model. FFI has established partnerships with key stakeholders in Ukraine’s private sector, government, and a local non-profit who are engaged and willing to assist in putting in place a fortification program. Through these local partnerships, FFI will provide boots-on-the-ground, peer-to-peer technical programming support. FFI’s innovative, multi-stakeholder approach can ensure a strong sell to the millers, addressing one of the major challenges Ukraine has faced in the past trying to put in place a national fortification program.

Activities will include setting the proper standards for the intended public health outcome as well as developing a best-in-class monitoring protocol to ensure mills have proper internal monitoring processes, government has realistic and effective external monitoring processes, and that any flour imports are monitored for compliance. The time is now for Ukraine to act to save lives and build a healthier future.

Photo: A. Krepkih/UNICEF-Ukraine

Americas: United States

Corn Masa Flour

In 1998, the United States (US) Food and Drug Administration (FDA) began to require that cereal grain products are fortified with folic acid to address micronutrient deficiency among women of reproductive age and prevent disabling birth defects of the brain and spine also known as neural tube defects (NTDs). Yet the law has a serious omission—it excludes a mandate to fortify corn masa flour and, as a result, excludes those who consume the most masa in the US: the Hispanic community.

The Problem

The omission of masa from mandatory FDA regulations has been associated with Hispanic women being 21% more likely than non-Hispanic women to have a pregnancy affected by an NTD. In fact, a 2021 US Centers for Disease Control and Prevention (CDC) analysis found no substantial impact of voluntary folic acid fortification of masa on red blood cell folate concentrations or on NTD risk for Hispanic women of reproductive age. Hispanics constitute around 20% of the US population and are a growing demographic in America; by 2050, demographers predict 30% of the total population will be Hispanic. Fortifying masa will ensure that nearly a third of America’s next generation of children will live a healthier future.

In 2006, a public-private working group successfully petitioned the FDA to allow folic acid to be added to masa. However, a subsequent study found that 20 months after the policy was rolled out, there was little to no impact on fortification of masa products sold in Hispanic markets nationally.

FFI assumes the lack of folic acid in masa stems from (1) retailers’ and consumers’ lack of awareness of fortification’s benefits and (2) food producers’ reluctance to incur additional costs when, in fact, the true cost of fortification is 16 US cents per person per year—a miniscule cost for a tremendous outcome. The project will address both concerns with community-led, evidence-based engagement.

Our Solution

FFI proposes to engage a link of the masa supply chain that both sets and satisfies demand—retailers—to energize bottom-up and top-down drivers for change. Fortification of masa that is in line with US standards will prevent birth defects and anemia, promote nutritional equity for current and future generations of Hispanic Americans, and contribute to increased human potential and reduced healthcare costs.

With additional funding, FFI would:

• Conduct a thorough supply chain diagnostic and market analysis of masa and masa products to better understand the market and better address retailers’ potential concerns or questions.

• Provide communication trainings for community members most directly impacted by folic acid deficiencies: parents of children with NTDs and neurosurgeons who treat children with NTDs.

• Connect community advocates with retailers in FFI meetings to insist that all masa, as well as any products containing 60% or more masa flour as a base, are fortified with folic acid.

• Provide technical assistance to food producers seeking to fortify.

• Assess effectiveness of advocacy efforts through nation-wide sampling.

Photo: Seoulful Adventures

Latin America

Wheat Flour and Maize Flour

Since 2009, the World Health Organization has published recommendations for the types of iron and the concentration levels of nutrients for wheat and maize flour fortification. Similar information for rice is now available from research led by the World Food Programme.

Nearly every country in Latin America was fortifying grains before these recommendations were available, however. Consequently, the fortification standards of many countries in this region are not using globally recognized effective forms of iron or amounts of other nutrients.

Further funding would allow FFI to:

• Lead two workshops (one in Spanish in South America and another in English in the Caribbean) to guide county leaders to harmonize their existing grain fortification standards with global recommendations. FFI has led such workshops in Asia, Africa, and the Middle East.

• Review quality control measures currently used in flour production facilities and government inspectors' food safety practices to ensure capabilities exist for monitoring the type and amount of nutrients added to flour.

Photo: Linda Beaverson

Latin America

Rice and Maize Flour

All 33 countries in Latin America require millers to fortify wheat flour with vitamins and minerals that are essential to health at every stage of life. Though several countries have seen positive health impacts of wheat flour fortification, including a dramatic reduction in debilitating birth defects caused by a lack of folate, evidence suggests that deficiencies of key vitamins and minerals persist in Latin America. This could be due to several factors. In some countries where there is high consumption of maize flour and rice, these foods are not fortified. Maize flour and rice may reach different consumers that do not consume wheat flour. Additionally, certain nutrients that are technically difficult to add in fortification may benefit from being spread across multiple food vehicles rather than concentrated in one. 

Six out of 33 countries have mandatory fortification of maize and 4 have mandatory fortification of rice. In 19 Latin American countries, more than 75 grams of rice or maize flour per person per day (g/c/d) is available for consumption and one or both food vehicles do not have mandatory fortification legislation, making it worthwhile to consider whether fortifying another cereal grain would provide additive or complementary nutritional benefit to fortification of wheat flour.

Countries with >75 g/c/d of rice or maize flour available for consumption that do not have existing mandatory fortification of rice or maize flour:

In order to take a regional approach to identifying fortification opportunities, FFI would:

• for each country, complete a rice and/or maize supply chain and country analysis in order to determine the feasibility of fortifying rice and/or maize based on industry capacity;

• conduct a desk review of the burden of disease in each country to assess the need for large scale food fortification from existing data;

• study the implementation programs of the other cereal grains that are fortified in these countries;  

• analyze food consumption or household expenditure surveys (where data are available) to understand the additive benefit of fortifying rice and the populations reached; 

• recommend whether fortified rice and/or maize would add value to countries' existing fortification program, and if relevant, suggest complementary fortification standards; and

• prepare and provide a final report and presentation to relevant governments.

Photo: Kate Tann