In order to direct you to the literature you need to specify the form of the iron you propose to use to fortify wheat flour as the form plays an enormous impact on what gets biologically absorbed and can be as low as 2% when added in a phytate rich diet. . For your information - You can contact GAIN who have extensive experience over 8 years fortifying the wheat flour in Jordan with electrolytic iron and which has shown little impact or improvement in the general iron status of the population. In South Africa for example over a 10 year period where both maize and wheat flour has been fortified with electrolytic iron - the clinical evaluation show iron status has not improved and in fact has gone backwards. You can also refer to Lynnette Neufeld, MI chief technical adviser who has reported that in most countries where MI works there are high levels of anaemia and folic acid deficiency during pregnancy, despite almost all of the countries having iron-folic acid supplementation for pregnant women in their health policies and including the products in their standard drug procurement lists, she said. “these policies and the supplements are in place but we are not seeing improvements, something is amiss.” The MRC (Medical Research Council) in South Africa has got published results in the Journal of Nutrition and they report Fortifying Brown Bread with Ferrous fumerate, electrolytic iron or sodium iron EDTA does not affect iron status of South African children. I am happy to send you a copy of this published article.

I would also be interested in the papers from South Africa regarding the impact if any of iron fortified flour on women's and children's iron status. I am currently working in a southern African country where the discussion has commenced about developing a national food fortification program. I have my reservations that such an approach will have the impact on the target group (pregnant women and children under 5) desired. Children simply don't consume large enough quantities of fortified flour for it to significantly contribute to improved iron status. I would however like to gather as much literature on the subject as possible to help guide and assist the country to develop an appropriate response to micronutrient deficiency prevention and control.

Please send me an email address to info@epap.co.za and will email you the MRC paper. You are correct about the difficulties of making a person nutrient replete in iron needs using low bio available iron nutrients. The numbers spell out the problem. If you fortify the wheat flour at 4mg per 100 grams using an inorganic refined iron form - at an absorption rate of 2% - only 0.08mg have a possibility of being absorbed biologically. A normal male adult requires at least 1mg biologically absorbed daily whereas an adolescent female - the number is much higher. To address even a 1mg absorbed daily amount of iron using such low bio available form of iron using a wheat fortified at 4mg of iron per 100 grams - the person would require to consume 1250 gram of wheat a day which would equate to 6 plus loaves of bread which is of course an impossible task even for the hungry. To compound the challenge of finding a solution with this approach - there are 2 added problems - the first is you cannot address the problem by adding more iron per 100 grams in order to reduce the number of loaves of bread they must eat daily. Because the taste profile would be affected by high levels of electrolytic iron - this is not an option. The other more serious problem is the reality that at a 2% biological absorption - 98% of the iron not biologically absorbed must go somewhere. Some of this non absorbed iron will be excreted in black feces and some will be filtered out by organs such as the liver where it could build up into a toxic overload. So what this means is that if somebody could consume 6 loaves of bread a day in order to get their daily absorbed iron requirement of 1mg - then there would be a possible build up of 47.04 mg of iron daily that the body would see as a foreign body and would want to to get rid of.

Hi 1. Abstract from recent paper "Foods, Fortificants, and Supplements: Where Do Americans Get Their Nutrients?" in Journal of Nutrition, September 22, 2011 by Victor L. Fulgoni III, Debra R. Keast, Regan L. Bailey, and Johanna Dwyer Limited data are available on the source of usual nutrient intakes in the United States. This analysis aimed to assess contributions of micronutrients to usual intakes derived from all sources (naturally occurring, fortified and enriched, and dietary supplements) and to compare usual intakes to the Dietary Reference Intake for U.S. residents aged =2 y according to NHANES 2003–2006 (n = 16,110). We used the National Cancer Institute method to assess usual intakes of 19 micronutrients by source. Only a small percentage of the population had total usual intakes (from dietary intakes and supplements) below the estimated average requirement (EAR) for the following: vitamin B-6 (8%), folate (8%), zinc (8%), thiamin, riboflavin, niacin, vitamin B-12, phosphorus, iron, copper, and selenium (<6% for all). However, more of the population had total usual intakes below the EAR for vitamins A, C, D, and E (34, 25, 70, and 60%, respectively), calcium (38%), and magnesium (45%). Only 3 and 35% had total usual intakes of potassium and vitamin K, respectively, greater than the adequate intake. Enrichment and/or fortification largely contributed to intakes of vitamins A, C, and D, thiamin, iron, and folate. Dietary supplements further reduced the percentage of the population consuming less than the EAR for all nutrients. The percentage of the population with total intakes greater than the tolerable upper intake level (UL) was very low for most nutrients, whereas 10.3 and 8.4% of the population had intakes greater than the UL for niacin and zinc, respectively. Without enrichment and/or fortification and supplementation, many Americans did not achieve the recommended micronutrient intake levels set forth in the Dietary Reference Intake. 2. You could find a good resource in the Flour Fortification Initiative website: [url]http://www.sph.emory.edu/wheatflour/[/url]

Thanks a lot,

In general, I think staple food fortification has played an immensely important role in improving the micronutrient status of populations, and remains one of the most successful public health nutrition interventions. Two other papers that might be useful for the southern Africa context : 'Efficacy of iron-fortified whole maize flour on iron status of schoolchildren in Kenya: a randomised controlled trial' Andango et al. Lancet, 369, 1799 - 1806 (2007) 'Maize meal fortification is associated with improved vitamin A and iron status in adolescents and reduced childhood anaemia in a food aid-dependent refugee population' Seal et al. Public Health Nutrition, 11, 720 - 728 (2008) Of course, when it comes to pregnancy, the iron requirements are so high that supplementation is required. In this particular population group food fortification will be useful but insufficient.

A word of caution of staple food fortification. It is indeed a very interesting approach to prevent nutrient deficiencies, and especially iron deficiency, in the general population. It has never been shown to my knowledge, however, to have a real impact on iron deficiency during the complementary feeding period. First, requirements in relation to energy are very high in this period. Also, quantities of staple food consumed by children in this age group is usually very small. Complementary foods at the age 6-9 mo usually provide about 200 kcal/day, and even if all of this is provided by fortified staple, this will not be enough to cover the needs of children in this age group. I realise the discussion so far was about school children and adolescent. This is a different issue

Thanks Andre for this useful clarification for the discussion.

Andrew, you write that it is your belief that staple food fortification has played an immensely important role in improving the micronutrient status of populations, and remains one of the most successful public health nutrition interventions. As you then quote the paper by Anang'o, Pea et al. Lancet 2007; 369: 1799-1806, let’s look at iron fortification. This paper concluded that eating whole maize flour fortified with NaFeEDTA resulted in modest, dose-dependent improvements in children's iron status, but that fortification with elemental iron did not improve iron status. The key words are ‘modest’ for NaFeEDTA’ and ‘did not’ for elemental iron. Van Stuijvenberg et al [Br J Nutr (2006); 95(3): 532-8] demonstrated that ferrous bisglycinate as the iron fortificant in brown bread performed better than electrolytic iron in a group of iron-deficient school children over a period of 7.5 months. Their later study [American Society for Nutrition J. Nutr. (2008); 138: 782-786] further concluded that electrolytic iron, NaFeEDTA and ferrous fumarate at the level currently used in South Africa is not effective in improving iron or haemoglobin status. Despite this and other evidence, elemental iron is the form of the mineral that is most often used to fortify cereal flours. This is not what I would call ‘one of the most successful public health nutrition interventions’.

In general I agree that much of the fortification literature suggests limitations in its impact and that for toddlers in particular, impact is likely to be limited. However, rice fortification has so far shown itself to be promising in spite of the poorly absorbed form that is used (ferric pyrophosphate, which is white). In one study in Brazil, it even outperformed iron drops in toddlers. (Beinner MA, Velasquez-Meléndez G, Pessoa MC, Greiner T. Iron-Fortified Rice Is As Efficacious As Supplemental Iron Drops in Infants and Young Children. Journal of Nutrition 2010 Jan;140(1):49-53, which is available in full text for free on the journal website.)

Thanks Ted for flagging this important paper. My previous comment referred to the lack of evidence of current staple food fortification programmes to prevent or treat iron deficiency in infants and young children. The paper you mention, if I understood correctly, used a special rice with a fortification level of 0.25 mg/g, much higher than what is used for staple food fortification (typically 10 times less). Can you confirm this point ? I noted that in the discussion of this paper, it is mentioned that this level could be used in staple food fortification programmes. Maybe, but this is not the case in current programmes which use low fortification levels as far as I know. So, I still believe one should be sceptical about the relevance of current staple fortification programmes to prevent or treat iron deficiency in infants and young children, which is regrettable as it is precisely in this age group that iron deficiency is the most common.

Andre, the level of fortificant used in that study was intended to provide about the same amount of iron as an infant would get from the prescribed dosage of iron drops (which at the time the study was being planned became the standard of care for ALL infants in Brazil. So it was higher than usual in a fortified food, but not at treatment levels. Keep in mind what what counts is not the amount of iron in the food, but the amount that is absorbed, an extremely complex issue. In the case of FPP, absorption depends on how finely ground it is. The type available in Brazil is not quite as finely micronized as the more commonly used German version and thus we estimated that as little as 1% would likely be absorbed. So viewed from that perspective, the level we used was actually not particularly high.

Interesting debate on the treatment of iron deficiency though food fortification… My comment relates to form and bio availability in redressing micronutrient deficiency. The comment by Andrew Seal is important. It represents a significant mindset that believe this incomplete perception: “In general, I think staple food fortification has played an immensely important role in improving the micronutrient status of populations, and remains one of the most successful public health nutrition interventions.” What concerns me about his comment is that the outcome is in fact something quite different. There is no clinical evidence to support this perception. I question why and how such perceptions actually exist. It is a fact - large-scale fortification interventions have been taking place for a number of years, yet there is little or no evidence to confirm that there is any significant positive impact on the health status of the populations. Does anyone have references? Dr Douglas’s posting confirms what known science and clinical evidence confirms - it is not possible to effectively address iron deficiency with approaches presently used in such programs. Is it not an exercise in futility to add a sensitive molecule such as Vitamin A to food products that are cooked and which will be destroyed by light/heat? How is it useful to fortify staple foods with electrolytic iron that has biological absorption rates that are so low they cannot possibly have an impact to effectively address iron deficiency? Again I ask: why and how is it possible that there is such a wide spread perceptions that such programs are making an impact on public health? Why is there such a deafening silence from the experts on such basic known issues and why are they not asking the same questions that I do? We should all be extremely worried about these incomplete perceptions. They are believed by well resourced decision-makers at a political and Institutional level such as the WHO where guidance notes direct programs along a path that can have little impact on addressing the problem. Should we not all be extremely concerned about programs like the SUN initiative (Scale up Nutritional) that may scale up initiatives that have little impact in addressing this serious health issue, unless effective solutions are recognised. A quote by Andre Briend on his words of caution on food fortification – “It has never been shown to my knowledge, however, to have a real impact on iron deficiency during the complementary feeding period.” How is it possible that millions of dollars are spent on supplementary feeding to address deficiencies where little or no evidence indicates that the “common” approach used is effective? Where are the governance structures that should be questioning the “common approach” that known science indicates does not work? How are these programs implemented without clinical evidence to show they are safe and cost effective? Professor Ted Grainer in his posting confirms a 1% absorption rate for micronized iron for the type of iron used in the Brazilian programs. Known science confirms that the forms of iron used in “large scale” fortification programs have similar low biological absorption levels. Has anyone investigated the potential health hazards especially to young babies, caused by the 99% of the iron that is not biologically absorbed? Yes, we know some will be liberated in black stool faeces. Should we not be concerned about the tons of iron added to the food chain? The iron is absorbed and filtered out by the body because it sees the iron as a foreign toxic intrusion, unless the form of iron is quite specific. That micronutrient deficiencies caused by our compromised food chain is creating enormous and unaffordable health challenges is not in question. That we must find solutions to effectively reverse and address this issue should be our collective focus. Effectively “walking the talk” to restore the integrity of nutrients in the food chain is our challenge. Basil Kransdorff Ashoka Fellow CEO e’Pap Technologies

We have invited WFP to comment on this issue, since they are involved in providing fortified staple food commodities in emergencies. While awaiting feedback, Rita Bhatia (former WFP) has offered the following references that might be of interest: Consumption of Iron Fortified Wheat Flour and Iron Deficiency Among Women in a Cross-Sectional Survey. Kirsten A. Grimm, Kevin M. Sullivan, Deena Alasfoor, Ibrahim Parvanta, Ali Jaffer Mohammed Suleiman, Meenu Kaur, Fatima Obaid Al-Hatmi, Laird J. Ruth. Emory University, Atlanta, Georgia, USA; Centers for Disease Control and Prevention, USA; Ministry of Health, Sultanate of Oman [url]http://www.ennonline.net/resources/908[/url] Evaluation of the potential effectiveness of wheat flour and salt fortification programs in five Central Asian countries and Mongolia, 2002–2007. Shamil Tazhibayev, Oksana Dolmatova, Galina Ganiyeva, Khotambek Khairov, Feruza Ospanova, Dalkhjav Oyunchimeg, Dilorom Suleimanova, and Nevin Scrimshaw. Food and Nutrition Bulletin, vol. 29, no. 4 © 2008, The United Nations University [url]http://www.ennonline.net/resources/909[/url] Impact of fortification of flours with iron to reduce the prevalence of anemia and iron deficiency among schoolchildren in Caracas, Venezuela: A follow-up. Miguel Layrisse, María Nieves García-Casal, Hernán Méndez-Castellano, Maritza Jiménez, Henry Olavarría C., José F. Chávez, and Eglis González. Food and Nutrition Bulletin, vol. 23, no. 4 © 2002 [url]http://www.ennonline.net/resources/910[/url] The effectiveness of fortified flour on micro-nutrient status in rural female adults in China. Junsheng Huo, Jing Sun, Jian Huang, Wenxian Li, Lijuan Wang, Lilian Selenje, Gary R Gleason, Xiaodong Yu. 2011. Asia Pac J Clin Nutr 2011;20 (1):118-124. [url]http://www.ennonline.net/resources/911[/url] She has also mentioned a piece of work in process on Summary of Impact of Iron Fortification of Wheat Flour: Effectiveness Data. This should be available later this year. I hope these may be of some use. Best wishes Tamsin