expert opinion

Improving nutrition with flour fortification

July 1, 2013

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Becky Handforth, Flour Fortification Initiative, Brussels, Belgium

“Populations worldwide are at risk for micronutrient deficiencies even when caloric intake is sufficient. This phenomenon is also called “hidden hunger” because deficiency symptoms are rarely apparent until individuals reach a clinically severe stage, at which point certain consequences may be irreversible. Micronutrient deficiencies in essential nutrients can increase one’s risk for fatigue, anemia, birth defects, blindness, impaired growth, dimi-nished neurological capacity, osteoporosis, and poor immunological response, among other things. Each of these conditions has a negative impact on the quality of life of the affected individuals and their family members. Although Europe is considered one of the most developed parts of the world, intake of specific essential nutrients remains suboptimal in the region. Bread is a highly affordable and accessible staple food in Europe, so if European countries would fortify flour, the majority of the populations would have access to more essential vitamins and minerals without necessitating a change in behavior.

The practice of adding nutrients to wheat flour to promote health and improve nutrition was initiated in the 1940s and 1950s by countries such as the United Kingdom, Canada and the United States. This public health intervention is internationally acknowledged as being affordable, technically feasible, and effective by many reliable entities such as the World Health Organization (WHO), UNICEF and the US Centers for Disease Control and Prevention (CDC). Currently, 75 countries possess mandates to fortify at least one type of commonly consumed wheat flour with iron and/or folic acid. Notably, however, most countries in Western Europe have not embraced this initiative. Iron-deficiency anemia is a common anemia (low red blood cell or hemoglobin levels) caused by insufficient dietary intake and iron absorption. European populations are not exempt from anemia. When using anemia in women of child-bearing age as an indicator, countries in Europe are classified mainly as having a mild or moderate public health problem (1). However, the prevalence of anemia is often greater among pregnant women and preschool-aged children. Folic acid, when consumed appropriately before and during pregnancy, can decrease the risk of children being born with neural tube defects (NTDs) such as spina bifida or anencephaly. The intake of folic acid in many European countries is suboptimal (2). Vitamin B12 and vitamin D deficiencies are also emerging issues in the region. Each of these nutrients, which are lacking in the diets of European populations, can be added to flour to address public health risks.

Europe is an ideal region in which to fortify flour given its population’s high consumption of wheat flour-based products, its highly industrialized flour-milling sector, and its strong transportation infrastructure. Studies show that flour fortification programs around the world do have a positive impact on health. The planning of fortification programs considers local food consumption patterns, assesses the nutritional needs of the population, conducts an industry analysis, creates a national fortification alliance involving the public, private and civil sectors, and enacts mandatory legislation for flour fortification. Flour fortification is a wise invest-ment and a low-cost intervention in addition to the other economic benefits, i.e. savings on medical costs and indirect costs such as lost productivity and caregiver expenses (3, 4). While the annual cost of this interven-tion depends on the types of vitamins and minerals added to the flour and the quantities of these necessary to achieve the desired health impact, the investment per person per year usually amounts to less than 0.16 euros.

Despite the proven economic and health benefits of fortifying flour, concerns about flour fortification are still raised by governments and consumers in Europe. However, there is evidence that

mandatory flour fortification alone does not cause people to consume more than the tolerable upper intake levels of folic acid and iron (5).

  • folic acid fortification does not cause cancer (6-8) or mask vitamin B12 deficiency (9-11).
  • iron fortification poses no significant risk to individuals with disorders that impair iron regulation, such as thalassemia and hemochromatosis (12, 13). Individuals diagnosed with such conditions require appropriate clinical management to maintain their health regardless of whether or not flour fortification is implemented in their country (14-16). Given the vital role iron plays throughout the life cycle, it would be negligent to withhold iron fortification from the greater population that stands to benefit (12, 14).
  • a targeted approach that urges women to take folic acid supplements before conception is less effective than the practice of fortifying flour with folic acid (17-20).

In addition, some consumer groups suggest that fortification will render bread impure. However, as the milling and baking industries have evolved over time to meet consumer demands regarding flavor, texture and longer product shelf-life, ingredients such as improvers and emulsifiers are now commonly utilized. Consequently, even unfortified bread often contains ingredients that, in the strictest sense, reduce the purity of the product. Moreover, consumers can still choose unfortified products in countries with mandatory flour fortification because select types of flour and flour-based products are typically exempt from complying with the legislation.”

Based on: Handforth B. and Zimmerman S. Improving Nutrition in Europe – Renowned Experts Highlight Flour Fortification. SIGHT AND LIFE. 2013; 27(1).

References

  1. World Health Organization. Worldwide prevalence of anaemia 1993–2005: WHO Global Database on Anaemia. 2008. www.who.int/vmnis/anaemia/en/.
  2. Viñas B. R. et al. Projected prevalence of inadequate nutrient intakes in Europe. Ann Nutr Metab. 2011; 59(2–4):84–95.
  3. Horton S. and Ross J. The Economics of Iron Deficiency. Food Policy. 2007; 32(1):141–143.
  4. Yi Y. et al. Economic burden of neural tube defects and impact of prevention with folic acid. Eur J Pediatr. 2011; 170(11):1391–1400.
  5. Yang Q. et al. Folic acid source, usual intake, and folate and vitamin B12 status in US adults: (NHANES) 2003–2006. Am J Clin Nutr. 2010; 91(1):64–72.
  6. Clarke R. et al. Effects of lowering homocysteine levels with B vitamins on cardiovascular disease, cancer, and cause specific mortality meta-analysis of 8 randomized trials involving 37,485 individuals. Arch Intern Med. 2010; 170(18):1622–1631.
  7. Wein T. N. et al. Cancer risk with folic acid supplements: a systematic review and meta-analysis. BMJ Open 2012; 2(1).
  8. Hankey G. C. et al. Treatment with B vitamins and incidence of cancer in patients with previous stroke or transient ischemic attack results of a randomized placebo- controlled trial. Stroke. 2012; 43(6):1572–1577.
  9. Dickinson C. J. Does folic acid harm people with vitamin B12 deficiency? QJM. 1995; 88(5):357–364.
  10. Mills J. L. et al. Do high blood folate concentrations exacerbate metabolic abnormalities in people with low vitamin B12 status? Am J Clin Nutr. 2011; 94(2):495–500.
  11. Ministry for Primary Industries. Scientific evaluation of comments on submissions received on the future of folic acid fortification in New Zealand, MPI Technical Paper No: 2012/25. 2012.
  12. Hurrell R. et al. Revised recommendations for iron fortification of wheat flour and an evaluation of the expected impact of current national wheat flour fortification programs. Food Nutr Bull. 2010; 31(1):S7–S21.
  13. Gillespie S. Major Issues in the control of iron deficiency. The Micronutrient Initiative. 1998.
  14. Brittenham G. M. Safety of Flour Fortification with Iron. Columbia University. 2004.
  15. Bothwell T. H. Overview and mechanisms of iron regulation. Nutr Rev. 1995; 53(9):237–245.
  16. International Nutrition Foundation and Micronutrient Initiative. Preventing iron deficiency in women and children: Technical consensus on key issues. A UNICEF/UNU/WHO/MI Technical Workshop, 1998.
  17. Paulik E. et al. Preconceptional and prenatal predictors of folic acid intake in Hungarian pregnant women. Eur J Obstet Gynecol Reprod Biol. 2009; 145(1):49–52.
  18. Pinto E. et al. Dietary intake and nutritional adequacy prior to conception and during pregnancy: a follow-up study in the north of Portugal. Public Health Nutr. 2009; 12(7):922–931.
  19. Baykan Z. et al. Awareness, knowledge, and use of folic acid among women: a study from Turkey. Arch Gynecol Obstet. 2011; 283(6):1249–1253.
  20. Brough L. et al. Social and ethnic differences in folic acid use during preconception and early pregnancy in the UK: effect on maternal folate status. J Hum Nutr Diet. 2009; 22(2):100–107.