Biofortification and fortification of wheat flour: Qualitative analysis for implementation and acceptance.

Fortification of wheat flour with folic acid may reduce the risk of neural tube defects; however, this outcome was only reported in one non-RCT. Fortification of wheat or maize flour with folic acid (i.e. alone or with other micronutrients) may increase erythrocyte and serum/plasma folate concentrations. Evidence is limited for the effects of folic acid-fortified wheat or maize flour on haemoglobin levels or anaemia. The effects of folic acid fortification of wheat or maize flour on other primary outcomes assessed in this review is not known. No studies reported on the occurrence of adverse effects. Limitations of this review were the small number of studies and participants, limitations in study design, and low-certainty of evidence due to how included studies were designed and reported.

India has a very high burden of malnutrition, including micronutrient malnutrition. According to National Family Health Survey IV (2015-16), more than 50 percent of all women of reproductive age and more than 45 per cent of pregnant women were found anemic. The anemia prevalence among young children is about 59 percent, and in men, it is about 23 percent. In rural areas of India, it is a practice that majority of households grind their wheat grains in small scale mills (chakki ) located near to their homes instead of buying packaged wheat flour, wheat flour fortification through these small chakkis is a good option to reduce the burden of micronutrient deficiency in rural and tribal areas. The primary objective of this research study is concerned with assessing the effectiveness of wheat flour fortification in terms of knowledge, attitude and practices of community towards using fortified wheat flour. This study has been done in Salumbar block of Udaipur district in Rajasthan. The sample size calculated for the study was 400. Total sample was collected from 20-gram panchayats. In addition to these, 50 chakki operators and 10 key stakeholders like Medical Officer, Sarpanch, ANM, Anganwadi worker, School Teacher were identified for the study. The research studies done in many small-scale flour fortification programmes showed improvement in hemoglobin levels among community especially women and adolescent girls. The data analysis in this study revealed that around 73 percent of sampled households are using fortified wheat flour on regular basis. Eighty eight percent of respondents opined that fortified wheat flour is beneficial and normally beneficial for women health while on significance of fortified wheat flour for new born health, 93 percent responded that it is highly beneficial, beneficial or normally beneficial. More than 70 percent of the stakeholders have good knowledge on significance of fortified wheat flour on all above mentioned indicators. More than 73 percent of respondents agreed to pay a minimal amount for getting fortified wheat flour from small chakkis. Ninety percent of total stakeholders recommended that community is willing to pay additional minimal amount and thus they should regularly use the fortified flour. However, chakki operators highlighted technical issues related to electricity supply require to run a chakki, hampering their grinding process. The study reveals that fortified wheat flour is well accepted by the community. Households which are regularly using it, most of them did not find difference in its taste, colour, odour when compared to normal wheat flour. The issues raised by chakki operators need to be dealt while implementing such fortification program. Implementation of wheat flour fortification model in rural areas through small chakkis could be an effective approach in reducing prevalence of micronutrient malnutrition among community if extensive social and behaviour change communications activities are undertaken for improving knowledge and attitude of community.

Eating food items containing wheat flour fortified with iron alone may have little or no effect on anaemia and probably makes little or no difference in iron deficiency. We are uncertain on whether the intervention with wheat flour fortified with iron increases haemoglobin concentrations improve blood haemoglobin concentrations. Consuming food items prepared from wheat flour fortified with iron, in combination with other micronutrients, has little or no effect on anaemia, makes little or no difference to iron deficiency and may or may not improve haemoglobin concentrations. In comparison to fortified flour with micronutrients but no iron, wheat flour fortified with iron with other micronutrients, the effects on anaemia and iron deficiency are uncertain as certainty of the evidence has been assessed as very low. The intervention may make little or no difference to the average haemoglobin concentrations in the population. None of the included trials reported any other adverse side effects. The effects of this intervention on other health outcomes are unclear.

After randomized, controlled trials established that consumption of folic acid before pregnancy and during the early weeks of gestation reduces the risk of a neural tube defect (NTD)-affected pregnancy, the United States Public Health Service recommended in 1992 that all women capable of becoming pregnant consume 400 microg folic acid daily. In 1998, folic acid fortification of all enriched cereal grain product flour was fully implemented in the United States and Canada. To provide guidance on national fortification of wheat and maize flours to prevent 50 to 70% of the estimated 300,000 NTD-affected pregnancies worldwide. An expert workgroup reviewed the latest evidence of effectiveness of folic acid flour fortification and the safety of folic acid. Recent estimates show that in the United States and Canada, the additional intake of about 100 to 150 microg/day of folic acid through food fortification has been effective in reducing the prevalence of NTDs at birth and increasing blood folate concentrations in both countries. Most potential adverse effects associated with folic acid are associated with extra supplement use not mandatory fortification. Fortification of wheat flour has a proven record of prevention in other developed countries. In 2009, 51 countries had regulations written for mandatory wheat flour fortification programs that included folic acid. NTDs remain an important cause of perinatal mortality and infantile paralysis worldwide. Mandatory fortification of flour with folic acid has proved to be one of the most successful public health interventions in reducing the prevalence of NTD-affected pregnancies. Most developing countries have few, if any, common sources of folic acid, unlike many developed countries, which have folic acid available from ready-to-eat cereals and supplements. Expanding the number of developed and developing countries with folic acid flour fortification has tremendous potential to safely eliminate most folic acid-preventable NTDs.

Wheat flour fortification can be a novel and effective food based approach to improve effective micronutrient deficiencies that affect millions of people worldwide especially in the developing countries. Wheat is an important cereal crop grown worldwide and its per capita consumption is high even in the developing countries. Being a most popular dietary food component, fortification of wheat flour with micronutrients like iron, vitamin A, folic acid, zinc, and iodine is expected to be the most effective strategy to overcome the related deficiencies and, if mandated, could be helpful in achieving the international health goals. However, on the other hand food fortification (Direct mixing) with micronutrients might cause unwanted sensory changes and interaction with food components resulting in a lower bioavailability. Microencapsulation may be helpful to prevent unwanted sensory changes and diminish micronutrients interactions with wheat flour components. The current review will focus on the technical issues related to the fortification (Direct mixing) of wheat flour and prospects of microencapsulation technology in fortification.

Consumption of foods made with wheat flour, particularly instant noodles, is increasing in Asia. Given this trend, fortifying wheat flour with vitamins and minerals may improve micronutrient intake in the region. The objective of this review was to understand what is known about fortifying wheat flour used to make instant noodles. A literature review of seven databases was performed using the search terms "noodle" and ("Asian" or "instant"). Grey literature was requested through a food fortification listserv. Articles were title screened first for relevance and duplicity, with exclusion criteria applied during the second round of abstract-level screening. This review considered studies examining simulation, retention, sensory, bioavailability, efficacy, and effectiveness of instant noodles made with fortified wheat flour. Fourteen relevant documents were reviewed for simulation (n=1), retention (n=11), and sensory studies (n=3). The documents revealed that instant noodles produced from fortified wheat flour have potential to improve nutrient intakes, have high retention of most nutrients, and provoke no or minimal changes in sensory characteristics. The available literature indicates that using fortified wheat flour for instant noodle production results in retention of the added nutrients, except thiamin, with no significant sensory change to the final product. Given the rising consumption of instant noodles, production of this item with fortified wheat flour has potential to improve nutrient intakes in Asia. This review provides a resource for the design of a wheat flour fortification program in countries where a large proportion of wheat flour is consumed as instant noodles.

Early Program Assessment of the Haryana Wheat Flour Fortification Program, India

Anaemia is a condition where the number of red blood cells (and consequently their oxygen-carrying capacity) is insufficient to meet the body's physiological needs. Fortification of wheat flour is deemed a useful strategy to reduce anaemia in populations. To determine the benefits and harms of wheat flour fortification with iron alone or with other vitamins andminerals on anaemia, iron status and health-related outcomes in populations over two years of age. We searched CENTRAL, MEDLINE, Embase, CINAHL, 21 other databases and two trials registers up to 21 July 2020, together with contacting key organisations to identify additional studies. We included cluster- or individually-randomised controlled trials (RCTs) carried out among the general population from any country, aged two years and above. The interventions were fortification of wheat flour with iron alone or in combination with other micronutrients. We included trials comparing any type of food item prepared from flour fortified with iron of any variety of wheat DATA COLLECTION AND ANALYSIS: Two review authors independently screened the search results and assessed the eligibility of studies for inclusion, extracted data from included studies and assessed risks of bias. We followed Cochrane methods in this review. Our search identified 3538 records, after removing duplicates. We included 10 trials, involving 3319 participants, carried out in Bangladesh, Brazil, India, Kuwait, Philippines, South Africa and Sri Lanka. We identified two ongoing studies and one study is awaiting classification. The duration of interventions varied from 3 to 24 months. One study was carried out among adult women and one trial among both children and nonpregnant women. Most of the included trials were assessed as low or unclear risk of bias for key elements of selection, performance or reporting bias. Three trials used 41 mg to 60 mg iron/kg flour, three trials used less than 40 mg iron/kg and three trials used more than 60 mg iron/kg flour. One trial used various iron levels based on type of iron used: 80 mg/kg for electrolytic and reduced iron and 40 mg/kg for ferrous fumarate. All included studies contributed data for the meta-analyses. Iron-fortified wheat flour with or without other micronutrients added versus wheat flour (no added iron) with the same other micronutrients added Iron-fortified wheat flour with or without other micronutrients added versus wheat flour (no added iron) with the same other micronutrients added may reduce by 27% the risk of anaemia in populations (risk ratio (RR) 0.73, 95% confidence interval (CI) 0.55 to 0.97;5 studies,2315 participants; low-certainty evidence). It is uncertain whether iron-fortified wheat flour with or without other micronutrients reduces iron deficiency (RR 0.46, 95% CI 0.20 to 1.04; 3 studies,748 participants; very low-certainty evidence) or increases haemoglobin concentrations (in g/L) (mean difference MD 2.75, 95% CI 0.71 to 4.80; 8 studies,2831 participants; very low-certainty evidence). No trials reported data on adverse effects in children (including constipation, nausea, vomiting, heartburn or diarrhoea), except for risk of infection or inflammation at the individual level. The intervention probably makes little or no difference to the risk of Infection or inflammation at individual level as measured by C-reactive protein (CRP) (mean difference (MD) 0.04, 95% CI -0.02 to 0.11; 2 studies,558 participants; moderate-certainty evidence). Iron-fortified wheat flour with other micronutrients added versus unfortified wheat flour (nil micronutrients added) It is unclear whether wheat flour fortified with iron, in combination with other micronutrients decreases anaemia (RR 0.77, 95% CI 0.41 to 1.46; 2 studies,317 participants; very low-certainty evidence). The intervention probably reduces the risk of iron deficiency (RR 0.73, 95% CI 0.54 to 0.99; 3 studies,382 participants; moderate-certainty evidence) and it is unclear whether it increases average haemoglobin concentrations (MD 2.53, 95% CI -0.39 to 5.45; 4 studies,532 participants; very low-certainty evidence). No trials reported data on adverse effects in children. Nine out of 10 trials reported sources of funding, with most having multiple sources. Funding source does not appear to have distorted the results in any of the assessed trials. Fortification of wheat flour with iron (in comparison to unfortified flour, or where both groups received the same other micronutrients) may reduce anaemia in the general population above twoyears of age, but its effects on other outcomes are uncertain. Iron-fortified wheat flour in combination with other micronutrients, in comparison with unfortified flour, probably reduces iron deficiency, but its effects on other outcomes are uncertain. None of the included trials reported data on adverse side effects except for risk of infection or inflammation at the individual level. The effects of this intervention on other health outcomes are unclear. Future studies at low risk of bias should aim to measure all important outcomes, and to further investigate which variants of fortification, including the role of other micronutrients as well as types of iron fortification, are more effective, and for whom.

The aim of this study was to evaluate the effects of fortification of whole wheat flour with different iron compounds, such as ferrous sulfate (FS), ferrous fumarate (FF), reduced iron (RI), ferric sodium ethylenediaminetetraacetate (NaFeEDTA), microencapsulated ferrous sulfate (FSm) and microencapsulated ferrous fumarate (FFm), on quality parameters: color, titratable acidity, peroxide value (PV) and hexanal values, during 120days of storage. An iron content of 1.38mg/100g was quantified in non-fortified whole wheat flour and after fortification, the iron levels ranged from 4.80 to 6.29mg/100g. The fortification of whole wheat flour with different iron compounds showed changes on the quality parameters evaluated during storage with exception of the color. The whole flour acidity was affected mainly by NaFeEDTA. Compounds FS and FFm presented the highest PV in whole flour after 30days of storage. Whole flours fortified with FS and FSm presented higher hexanal levels after 30 and 90days of storage, respectively. Whole flours fortified with RI and NaFeEDTA presented more stability on quality parameters evaluated during storage period. Therefore, the different iron compounds, when used on whole wheat flour fortification, affect differently the quality of the product during storage.

A project for universal salt iodation with potassium iodate and wheat flour fortification with a vitamin-mineral premix was implemented in Azerbaijan, Kazakhstan, Kyrgyzstan, Mongolia, Tajikistan, and Uzbekistan between 2002 and 2007. To determine the potential effectiveness of the food fortification programs in improving the micronutrient status of selected families in a sentinel population in each country. An area was selected in each country in a sentinel population expected to have early access to iodated salt and fortified wheat flour. Within this area, an average of 40 families with a woman of reproductive age and two children between 2 and 15 years old were sampled at baseline. All the rounds of the study were carried out in women and children in the same households. Hemoglobin, serum ferritin, folic acid, and urinary iodine excretion were analyzed at baseline, one year, and three years later. In the third round in 2007 significant increases were observed in the average levels of blood hemoglobin, serum ferritin and folic acid, and urinary iodine. Corresponding decreases in the prevalence of anemia and increases in serum ferritin levels, folic acid, and iodine were found. Salt and wheat flour fortification resulted in a significant improvement in the micronutrient status of children and women living in sentinel households in the countries participating in the Asian Development Bank project. Sentinel studies were a cost-effective way of determining potential national effectiveness.

Zinc is an essential micronutrient that promotes normal growth, development and immune function. In the context of persistent dietary zinc inadequacies, large-scale food fortification can help fill the gap between intake and requirements. Burkina Faso mandates wheat flour fortification with iron and folic acid. We used activity-based cost modelling to estimate the cost of adding zinc to the country's wheat flour fortification standard assuming (1) no change in compliance with the national standard, and (2) a substantial improvement in compliance. We used household food consumption data to model effective coverage, that is, the number of women of reproductive age (WRA) predicted to achieve adequate zinc density (zinc intake/1000 kcal) with the addition of fortification to diets. Without interventions, the prevalence of inadequate dietary zinc density was ~35.5%. With no change in compliance, the annual average incremental cost of adding zinc to fortified wheat flour was $10,347, which would effectively cover <1% of WRA at an incremental cost of ~$0.54/WRA effectively covered. Improving compliance added ~$300,000/year to the cost of the fortification programme without zinc; including zinc added another ~$78,000/year but only reduced inadequate intake among WRA by 3.6% at an incremental cost of ~$0.45/WRA effectively covered. Although the incremental cost of adding zinc to wheat flour is low ($0.01/wheat flour consumer/year), given low levels of wheat flour consumption, zinc fortification of wheat flour alone contributes marginally to, but will not fully close, the dietary zinc gap. Future research should explore potential contributions of zinc to a broader set of delivery vehicles.

Food and Nutrition Security is heavily threatened by the onset of COVID-19 pandemic, and Pakistan is no exception. The most vulnerable segments including women and low wage workers are mainly relying on free or subsidized meals served by public and private sector managed food distribution networks (FDNs). These FDNs are mainly relying on wheat flour, which could be used as a fortification vehicle to provide essential nutrients after fortification for Zn, Fe, Folic acid and B 12 , during post COVID period. The aim of this project was to ensure that wheat flour, procured by selected FDNs, was replaced with high quality fortified wheat flour in daily distribution meals, so that more nutritious foods would reach the most vulnerable segments in Pakistan. This pilot project executed through different private sector managed food distribution networks (FDNs), industrial distribution networks (IDNs), and ration distribution networks (RDNs), and their regular wheat flour was replaced with quality fortified wheat flour. After selection and agreement with flour mills and FDNs, their employees were capacitated to produce and serve quality fortified flour. Alongside the provision and monitoring of quality fortified wheat flour, supplied to FDNs, the fortification quality was also assessed for fortification compliance, through analysis of added iron content. The agreements were signed with 11 flour mills, 11 FDNs, 6 RDNs, and 6 IDNs in 4 cities of Punjab i.e. Faisalabad, Lahore, Multan and Gujranwala; and 1 city of Sindh i.e. Karachi. Likewise, in total 858 people from these flour mills, FDNs and provincial regulatory authorities were capacitated to provide quality fortified flour. During the project period June to December 2021 around 1,722 tons of quality fortified flour was produced by selected flour mills and 8.6 million fortified meals were served to the vulnerable consumers (61.50% males and 38.50% females). Furthermore, the analysis revealed that the average content of added iron in case of all flour mills complied with the recommended fortification standards of Punjab Food Authority i.e. ≥15 mg/kg. Micronutrient fortified wheat flour provision to vulnerable populations through these FDNs is one of the best strategy to be adopted both by government as well as private sector to compliment the basic nutrition of vulnerable segments.

A national survey found that micronutrient deficiencies are prevalent in South African children, particularly calcium, iron, zinc, riboflavin, niacin, vitamin B6, folate, vitamin A, E and C. Mandatory fortification of maize meal and wheat flour were introduced in 2003 to combat some of the deficiencies found in children. To date however, there has not been a national survey on dietary intake in adults. The main objectives of this study were to evaluate the micronutrient intake of the diet consumed by the average adult South African by means of secondary data analyses and secondly to evaluate the effects of fortification on selected nutrient intakes. Secondary data analysis was carried out with numerous dietary surveys on adults to create a database that included sampling (and weighting) according to ethnic/urban-rural residence in line with the population census, of which 79% were black Africans and the majority resided in rural areas. The effect of fortification was evaluated by substituting fortified foods in the diet for the unfortified products. The combined database used in this study comprised 3229 adults. Mean calcium, iron, folate and vitamin B6 intakes were very low particularly in women. Mean intakes of most micronutrients were lower in rural areas. Fortification of maize meal and wheat flour (bread) raised mean levels of thiamine, riboflavin, niacin, vitamin B6 and folate above the recommended nutrient intakes (RNIs). In women, despite fortification, mean iron intakes remained below the RNIs, as did calcium since it was not in the fortification mix. The average dietary intake of adults was of poor nutrient density, particularly in rural areas. Fortification of maize meal and wheat flour (bread) considerably improved mean vitamin B6, thiamine, riboflavin, niacin, folate and iron intakes as well as the overall mean adequacy ratio of the diet.

Wheat Flour Fortification Is Unlikely to Benefit the Neediest in Guatemala

Determination of vitamin D3 (cholecalciferol) in wheat flour using a solid-liquid extraction and liquid chromatography-tandem mass spectrometry (LC-MS/MS).