Use nutrition data to plan fortification strategy

Nutritional anemia and neural tube defects are the two most common health concerns addressed by fortification. Data from your country on these two issues will help determine if fortification could be a helpful strategy.

Nutritional Anemia

Anemia can be caused by many factors, including deficiencies in iron, folic acid, zinc, riboflavin, vitamin A, and vitamin B12. Fortifying grains with these vitamins and minerals can help prevent anemia caused by nutritional deficiencies.

If available, compare anemia data for men and women in your country. Women in their childbearing years are more prone to anemia than men. If anemia among women ages 15 to 49 is higher than anemia among men in the same age group, then the anemia is most likely a result of iron deficiency. In that case, fortifying with iron will most likely make people less prone to iron deficiency anemia.

If men and women in the 15-49 age group have similar anemia statistics, then other factors such as other nutritional deficiencies or malaria or parasitic infections are probably causing the anemia. Other interventions will be necessary to reduce anemia in these populations.

Young children are especially vulnerable to iron deficiency between the ages of 6 and 24 months. Other health interventions may be needed for this age group.

For More Information:

• Look for anemia results on Demographic and Health Surveys.

• See the World Health Organization (WHO) Vitamin and Mineral Nutrition Information System (VMNIS) Database on Anemia.

• Select your country from our country profiles for selected anemia data.

• When reviewing anemia data, refer to this classification of anemia as a public health problem from WHO:

• ≤4.9% No problem

• 5.0-19.9 Mild problem

• 20.0-39.9 Moderate problem

• ≥40.0 Severe problem

Neural Tube Defects

All people need folic acid (vitamin B9) to produce and maintain healthy cells and avoid a certain type of anemia. Women who may become pregnant are encouraged to consume 400 micrograms of folic acid daily to help prevent birth defects of the brain and spine, also called neural tube defects (NTDs).

Countries that fortify flour with folic acid generally reduce the NTD prevalence to less than 10 per 10,000 births. When looking for NTD data, consider whether the results include loss of pregnancy or termination of pregnancy. NTD prevalence for only live births will misrepresent the NTD prevalence in all pregnancies.

Three types of birth defects are NTDs: spina bifida, anencephaly, and cephalocele. The International Classification of Diseases (ICD)  codes for those are:

• Anencephaly - ICD11 LA00.0-LA00.Z

• Cephalocele - ICD11 LA01

• Spina bifida - ICD11 LA02.0-LA02.Z

Hospital systems may be able to provide data on birth defects based on those codes.

For More Information:

• Some countries have entries in the Annual Report from the International Clearinghouse for Birth Defects Surveillance and Research.

• For 21 countries in Europe, see the EUROCAT European Surveillance of Congenital Anomalies.

• Country profiles on our website list NTDs per 10,000 births based on the above resources where available or estimates from other research.

Vitamin A Deficiency

Vitamin A deficiency diminishes the ability to fight infections, and it is the leading cause of childhood blindness. Vitamin A deficiency may also lead to anemia. Vitamin A can be added to wheat or maize flour, but it shortens the flour’s shelf life and increases the cost of flour fortification. Consequently vitamin A is more frequently added to rice, oils, margarine, or sugar. Read FFI's report "Vitamin A Stability After Wheat Flour Fortification" to learn more.

For data on vitamin A deficiency, see WHO's Global Prevalence of Vitamin A Deficiency in Populations at Risk 1995-2005. 

Zinc Deficiency

Zinc deficiency is one cause of childhood stunting, and zinc deficiency is also linked with diarrhoeal diseases, pneumonia, malaria.

WHO estimates that zinc deficiency affects about one-third of the world's population, with estimates ranging from 4% to 73% across subregions. Worldwide, zinc deficiency is responsible for approximately 16% of lower respiratory tract infections, 18% of malaria and 10% of diarrhoeal disease. About 1.4% of deaths worldwide were attributable to zinc deficiency.

See your country profile for the percent of the population at risk of inadequate zinc intake.

Food intake guides fortification nutrient levels

Learn what foods are frequently eaten in your country and set standards for the levels of nutrients to add via fortification based on this information.

Consider both the primary and secondary grains available. For example, rice may be the main cereal, but enough foods may be made with wheat that both rice and wheat flour fortification are needed.

To understand food intake, consider using these sources: 

• National food consumption surveys measure a population's food intake. They often use 24-hour recall methods and food frequency questionnaires. The surveys are often not available nationally. Other sub-national information is frequently available from ministries of health, non-governmental organizations, and nutrition departments at universities.

• Household Income and Expenditure Surveys (HIES) are multi-purpose instruments that usually report on grains, sugar, and oil. Note that expenditures do not always reflect consumption. Also, these are based on households rather than individuals, and the survey does not usually include foods eaten outside the home. The surveys can help determine geographic areas where a food is widely consumed. See this example from the Solomon Islands

• Panel surveys are sometimes conducted over time with representative households. These are usually annual. They can be used to track changes in food preferences and in a wide range of socioeconomic factors. Results are likely to be available from the National Bureau of Statistics. Some data sets are available from the International Food Policy Research Institute.

• Fortification Rapid Assessment Tools (FRAT) combine a simplified 24-hour recall and food frequency questionnaire. The six-part questionnaire provides a minimum amount of information about consumption patterns to help identify appropriate foods for fortification. FRAT questionnaire can be stand-alone surveys or added to an existing survey.

• Food Balance Sheets from the Food and Agriculture Organization of the United Nations (FAO) list food available per capita in a country. On the FAO website, choose the country, then the most recent year, and click “Show Data.” Or see our Country Profiles. The grain available data are from FAO. The amount for human consumption accounts for domestic production, imports, exports, grain that is stored or released from storage annually, grain used for animal feed, grain saved for seed, and grain that is wasted.

• The U.S. Department of Agriculture Foreign Agriculture Service has grain consumption data for some countries. On the website, under “categories,” choose “Grain and Feed.” Select the custom date and country. Then select the annual report from the results.

Oil and sugar are often practical food vehicles for vitamin A. Salt is commonly fortified with iodine. Milk often is fortified with vitamin D. Comprehensive food fortification programs will consider which foods or combination of foods have the potential to reach the largest number of people with the least cost. See the Global Fortification Data Exchange (GFDx) in English or in Spanish (en español). for information on oil and salt fortification in countries.

For More Information:

• Guidelines on Food Fortification with Micronutrients, published by the World Health Organization and FAO, is available in Chinese, English, and French.

• World Bank presentation at previous FFI workshop.