Fortify Grains to Prevent Nutritional Anemia

Anemia occurs when people lack hemoglobin to carry oxygen to tissues and muscles. Anemia causes debilitating fatigue and  impairs a child’s mental development. Pregnant women with anaemia are twice as likely to die during or shortly after pregnancy compared to those without anemia, according to an international study of more than 300,000 across 29 countries.

Nutritional anemia is caused by vitamin and mineral deficiencies [1]. Adding iron, riboflavin, folic acid, zinc, vitamin B12, and vitamin A to flour and rice during the milling process helps reduce the risk of nutritional anemia. Fortification does not address other causes of anemia such as genetic factors and infections. 

Food fortification is listed as a "relevant intervention" in this list of six key actions to reduce anemia.

In Costa Rica, anemia declined in women and children, and iron status in children improved after fortification [2]. Also, each year of flour fortification is associated with a 2.4% decrease in anemia prevalence among non-pregnant women [3]. In the United States, fortifying with folic acid has nearly eliminated folic acid deficiency anemia [4].

Read stories from people describing how anemia impacted their daily lives. Also see the economic and productivity consequences of anemia. UNICEF also recommends mass fortifcation as one strategy to prevent vitamin and mineral deficiencies.


All people need iron as it improves their capacity for physical activity and productivity. Iron helps children develop physically and mentally, and it improves the health of pregnant women.

Yet iron deficiency is “one of the most prevalent nutrient deficiencies in the world, affecting an estimated 2 billion people. In total, 800,000 (1.5%) of deaths worldwide are attributable to iron deficiency,” according to the World Health Organization (WHO) [5].

A WHO report published in 2015 estimates that 243,187,000 non-pregnant women of child-bearing age have anemia related to iron deficiency [6]. Assume each woman is 1.65 meters tall (5.41 feet). If they stood head to toe, they would extend 401,259 kilometers – enough to reach the moon and circle it.


Animal foods are the best natural source of iron [7]. Vitamin C can help people absorb iron. In contrast, several dietary factors limit iron absorption. Iron inhibitors include:

  • Calcium
  • Tannins in tea
  • Polyphenols in honey, legumes and many fruits
  • Phytates in legumes and whole grains [7].

Fortifying food with iron helps consumers avoid the consequences of iron deficiency with "remarkably little risk of adverse health effects." [8] See a two-page summary of fortification and iron deficiency.


[1] Nutritional Anemia. Sight and Life Press; 2007

[2] Martorell, R., et al. Effectiveness evaluation of the food fortification program of Costa Rica: impact on anemia prevalence and hemoglobin concentrations in women and children. American Journal of Clinical Nutrition, first published November 5, 2014.

[3]  Barkley, J., Wheeler, K., and Pachón, H. Anaemia prevalence may be reduced among countries that fortify flour. British Journal of Nutrition, available on CJO2015. doi:10.1017/S0007114515001646. 

[4] Odewole, O., et al. Near-elimination of folate-deficiency anemia by mandatory folic acid fortification in older US adults: Reasons for geographic and racial differences in stroke study 2003-2007. American Journal of Clinical Nutrition, published online 14 August 2013.

[5] The World Health Report 2002 -- Reducing Risks, Promoting Healthy Life. World Health Organization.

[6] The Global Prevalence of Anemia in 2011. World Health Organization.

[7] Dietary Supplement Fact Sheet; National Institutes of Health

[8] Brittenham, Gary, The Safety of Flour Fortification with Iron, Columbia University, paper presented at 2004 workshop for the Flour Fortification Initiative, now the Food Fortification Initiative.

Hear how Costa Rica fortified foods to prevent anemia from iron deficiency.

La anemia, debida a una deficiencia de hierro, causó que Helena Pachón tuviera que dejar de correr con su equipo de atletismo en la secundaria.

For guidance on determining a country's nutritional needs, contact Helena Pachon, FFI Senior Nutrition Scientist, at

If all the women in world with anemia from iron deficiency stood head to toe, they could reach the moon and circle it. This public health problem causes debilitating fatigue for millions of women and children. Let's face it together.