External Mill Monitoring of Wheat Flour Fortification Programs: An Approach for Program Managers Using Experiences from Jordan

James Wirth,Hanan Mas'D,Erin Nichols,Mary Serdula,Rawhieh Barham,Quentin Johnson

doi:10.3390/nu5114741

Abstract

The fortification of wheat flour with micronutrients is a common strategy to increase vitamin and mineral intake. While wheat flour mills are often inspected by agencies affiliated with national ministries to ensure compliance with national fortification standards, few countries use data derived from these inspections to construct an external monitoring system for use in program management and evaluation. The primary objective of this paper is to assess the performance of the external monitoring system utilized in Jordan according to the US Centers for Disease Control and Prevention’s Updated Guidelines for Evaluating Public Health Surveillance Systems. A secondary objective is to present mill monitoring results from 2009 to 2010 in order to demonstrate the data generated by the system. The review concludes that the data required for the system is representative, simple to collect, and can be collected in a flexible manner. The external monitoring system is acceptable to participating agencies and millers and is stable due to mandatory fortification legislation which provides the legal framework for external monitoring. Data on production of fortified flour and utilization of premix can be provided in a timely manner, but on-site mill monitoring and flour sample collection are more challenging due to resource constraints. The frequent collection of a small number of indicators can provide fortification program managers with timely information with which to base decisions. Jordan’s external monitoring system successfully documented the performance of each mill and the entire flour fortification program, and can serve as a model for other national fortification programs considering external monitoring approaches.

Highlights

The fortification of wheat flour with micronutrients is a common strategy to increase vitamin and mineral intake and is included as a key component in national health and nutrition strategies [1]
The gap in the provision of micronutrient premix occurred because the premix delivered in July 2009 contained Vitamin D erroneously, and program managers wanted to document Vitamin D deficiency through a national micronutrient survey conducted in 2010, so that deficiency rates could serve as a national baseline
Internal quality assurance (QA) processes and quality control (QC) tests related to fortification can be complemented and verified by external monitoring implemented by government health or food safety agencies

Summary

Introduction

The fortification of wheat flour with micronutrients is a common strategy to increase vitamin and mineral intake and is included as a key component in national health and nutrition strategies [1]. In addition to internal measures to assure quality, external monitoring measures are often implemented by national or sub-national agencies affiliated with national ministries of health to ensure that mills comply with national fortification standards [3] This is of particular concern where the fortification of flour is mandatory [4] or the government plays an active role in the implementation of the fortification program. The flour fortification program in Jordan began in 2002 [15] with iron (dried ferrous sulfate) and folic acid included in the micronutrient premix This micronutrient premix formulation was utilized until 2006 when the number of nutrients was increased to include zinc, and Vitamins A, B1, B2, B3, B6, and B12 [12].

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