Thank you for inviting me to speak today, and thank you to those who are attending this session.

I am the communications coordinator for the Food Fortification Initiative or FFI. Some of you may remember FFI as the Flour Fortification Initiative. We changed our name last year because we are adding rice to our scope of work. Since rice is rarely eaten as flour, it wasn’t reflected in our original name.

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Before I describe the new evidence for the health benefits of fortification, I’d like to ask you a question. Have any of you ever had anemia? Please raise your hand if you have. I promise I will not call on you to say anything.

I didn’t expect many hands to go up because anemia is more common in women dueto their monthly menstrual cycles, and I expected mostly men to be in this audience.

The reason I’m asking if you have ever had anemia is that flour and rice are most commonly fortified with iron to reduce the risk of iron-deficiency anemia. But if you have never had anemia, you can’t begin to understand why that is important. So let me share some stories of people who have had anemia.

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Last December I met Scott McNiven at a fortification advocacy meeting in Cape Town. He said when he had anemia it was like being a zombie – like he was moving through the day in slow motion. He couldn’t play with his children and couldn’t be productive at work. His anemia was caused by a parasite he got while swimming in a lake. Fortification cannot address that cause of anemia, but his experience is an accurate description of what anemia is like, regardless of the cause.

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When I had anemia from iron deficiency, it felt like I had jet lag all the time. No matter how much I slept at night, I struggled to concentrate and stay awake during the day. And for your information, a friend took this picture with a private jet for this project; this is not the kind of plane that FFI uses for business travel.

The thing I want you to know from these stories is that anemia does not simply mean that people are tired. It can interfere with all your daily activities.

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When women become pregnant, they need even more iron. This story is from a friend in Atlanta. Her iron deficiency anemia was diagnosed and treated. Untreated anemia in pregnancy can lead to low birth-weight babies, and that creates a host of other health problems. Iron deficiency in pregnancy also contributes to about 20 percent of the cases of maternal deaths globally, according to the World Health Organization.

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In 2011 researchers estimated that 801 million women and children had anemia. The total is more than the combined population of the countries listed in the red box. It includes:• 496 million non pregnant women• 32 million pregnant women• 273 million children

Imagine 801 million women and children as zombies throughout the world, or 32 million pregnant women fainting, and you’ll have a mental image of the toll this takes on global health.

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Like Scott’s example, anemia can be caused by many things other than iron deficiency. Fortification can only address the anemia caused by nutritional deficiencies. This is estimated to be a significant portion of anemia globally. As noted in the red box here, about half the anemia in women and 42% of the anemia in children in 2011 was attributed to iron deficiency.

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If you are thinking that people in your country do not have anemia because you live in an industrialized country, you might want to reconsider. This photo and quote is from a doctor in Turkey. She attributes her iron deficiency to the fact that she drinks a lot of tea. In Turkey, tea is a sign of friendship; simply not drinking it is hardly a cultural option even though tannins in tea are known to inhibit iron absorption. Phytates in grains also inhibit iron absorption.

The World Health Organization says iron deficiency is the only significantly present nutritional deficiency in industrialized countries.

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Peter Böhni is a member of the FFI Executive Management Team (EMT) and is Managing Director EPFL Innovation Satellite and Head Corporate Technology Value Nutrition for Bühler AG.

We talked about how it felt to have anemia at the last EMT meeting, so he began asking friends, colleagues, and neighbors if they had experienced anemia from a nutritional deficiency. He said he was astonished to find out so many of them had experienced anemia.

I challenge you to follow Peter’s example. Start asking women you know if they have ever had anemia. If they don’t remember, then they most likely have never had anemia. They would remember if they had. When you find people who have had anemia, ask them what it was like. I think you’ll hear more stories like these.

Now finally I will get to the topic that is the subject of my session, and it is good news.

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A study from Costa Rica was published in January this year that showed significant improvements in anemia and iron deficiency due to fortification.Costa Rica had been fortifying wheat flour with reduced iron, but that is not an effective iron compound for fortification. In 2002, the fortification standard for wheat flour was changed to ferrous fumarate. Also, ferrous bisglycinate was added to maize flour in 1999 and to liquid and powdered milk in 2001.A study that compared anemia and iron deficiency before and after these changes yielded the results on this slide. The authors of the study looked for other things that could have caused these improvements, but their only conclusion was that the changes were most likely from fortification.

Wheat and maize flour, milk, and rice are fortified with folic acid. A study published in 2011 showed that Costa Rica’s neural tube defect prevalence dropped from 12 per 10,000 births to 5.1 per 10,000 because foods were fortified with folic acid.

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Fiji has also had great success from fortifying wheat flour. You can see from this chart that it significantly reduced the prevalence of iron, folate and zinc deficiency, and anemia in women of child bearing age.

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Some of my colleagues at FFI analyzed anemia prevalence in countries that fortify wheat flour with anemia prevalence in countries that do not fortify wheat flour. When they started this research, 78 countries had mandates to fortify wheat flour alone or in combination with maize flour. Of those, only 12 had anemia data on women of reproductive agefor periods before fortification began and after fortification was implemented. They found 20 countries that were not fortifying that had at least two national surveys about anemia prevalence.

They adjusted the figures for things like malaria, since we know that it can cause anemia but malaria cannot be treated or prevented with fortification.

CLICK – Their findings are that each year of flour fortification was associated with a 2.5% decreased anemia prevalence.

Their research has been accepted for publication in the British Journal of Nutrition” but has not been published yet. If you will give me your business card today, I will be sure you get on the distribution list for FFI news so that you are alerted when things like this are published.

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Now I want to switch subjects and ask you another question. Raise your hand if you have become a parent or a grandparent in the last year. Again, I promise to not as you direct questions.

Congratulations to everyone who raised a hand. I trust this is joyous news for your family.

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Do you remember seeing an image like this from an ultrasound about halfway through the pregnancy? At this time the child’s organs and body systems are formed, and an ultrasound detects any problems. Usually everything is fine and the parents also find out if they’re having a boy or a girl.

This is also the point when neural tube defects can be identified. A neural tube defect is a devastating defect of the spine or brain.

In the next three slides, I have photos of children with neural tube defects. These can be disturbing, but I want you to see them briefly so you’ll understand why we advocate for fortifying with folic acid.

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Encephalocele is rare. It is a sac-like protrusion or projection of the brain and the membranes that cover it through an opening in the skull. The severity of encephalocele depends on its location. It is often linked to nervous system problems.

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Anencephaly is a type of neural tube defect that results in malformation of the brain. This is always fatal. We don’t really know how rare or common these are because pregnancies affected by anencephaly are often miscarried, and we have no records of that. If pregnancies affected with anencephaly are carried full term, the infant dies shortly after birth.

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The most common neural tube defect, or at least the most common one

reported, is spina bifida, which is when the baby’s spine is not formed

correctly. The severity of spina bifida depends on several factors, such as where along the spine the defect occurs. Spina bifida can be treated, but it cannot be cured.

Spina bifida can also lead to infant mortality. A study of children born with spina bifida in Ireland found these statistics. The main thing I want you to notice is the last bullet. See that of the live births of children with spina bifida, only 47% of the children were alive by their fifth birthday.

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The children who lived past their fifth birthday had varying degrees of physical

disability, as noted here.

You may be thinking that you rarely see children in wheelchairs or with

crutches in your country. If your country allows terminations of pregnancies,

then you are probably right. Remember that this study is from Ireland, where

abortion is not legal. We’ve found in many other countries in Europe, pregnancies affected by neural tube defects are most often terminated.

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Remember that neural tube defects are usually identified during an ultrasound about halfway during the pregnancy. By that time, the expectant mother is visibly pregnant, and the parents have probably told friends and relatives that they’re expecting a child. So imagine the emotional upheaval it creates to learn the infant has a neural tube defect.

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The mother pictured here told the British Broadcasting Corporation that learning her child had anencephaly was “soul destroying.”

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In 2011, a regular writer for UK’s Daily Mail newspaper wrote a first-person account about her experience in learning that the baby she was carrying had spina bifida. This is how she describes hearing the news during the ultrasound.

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Now for the good news. Most of these birth defects can be prevented if women

have 400 micrograms of folic acid, which is a form of vitamin B9, at the right

time. And if you’re like me, you’re thinking then why don’t women take folic

acid?

Here are some reasons women don’t get 400 micrograms of folic acid in time to prevent birth defect.

First, they’re not planning a pregnancy and haven’t given any thought to nutrition related to pregnancy. Neural tube defects occur within the first 28 days after conception, and women often don’t even know they are pregnant during that time. Starting to take folic acid after you know you are pregnant is usually too late for folic acid to have its protective effect.

Secondly, some women may not be aware of the recommendation to take folic acid. If they are not planning a pregnancy, they have not talked to their doctors about how to prepare.

Some women may not have access to supplements with folic acid or foods that are fortified with folic acid.

And fourth, some women may be relying on unfortified foods, thinking they can get plenty of folic acid from fruits and vegetables.

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We support diversified diets, but the problem with relying on unfortified foods is that the vitamin B 9 in food naturally is very hard for the body to absorb and use. To get the equivalent of 400 micrograms of folic acid a day from unfortified food, you would need to eat 4 slices of beef liver or 44.5 medium ripe tomatoes or 14.5 cups of raw broccoli or 17.5 cups of orange juice. That’s hardly a realistic daily expectation.

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The bioavailability (portion of the nutrient that is absorbed and utilized by the body) for folate naturally found in food (e.g. food folate) is about 40-50% lower than folic acid added to pills (e.g. supplements) and food (e.g. fortified food). Therefore, the current recommendations are that in the periconceptional period (before and immediately after conception) women consume, on a daily basis, 400 mcg of folic acid (NOT FOOD FOLATE) to reduce the risk of NTDs. There is insufficient evidence to comment on whether or not NTD risk can be decreased by consuming the equivalent of 400 mcg of folic acid daily through food (e.g. around 800 mcg of food folate). Thus, bottom line, the recommendation is for women to consume folic acid to reduce NTD risk.

Sources of folateThe two main sources of folate are food folate and folic acid delivered through supplements and fortified foods (Suitor & Bailey 2000). Food folate refers to the inherent folate content of food (Suitor & Bailey 2000). Because they contain between 100 and 200 μg of dietary folate equivalents per 100 grams of food, beef, liver, lentils and spinach are considered excellent sources of food folate (Suitor & Bailey 2000). However, the bioavailability of food folate is 40-50% lower than for FA (WHO 2004). Thus, for the purposes of reducing NTD risk, it is recommended that women consume 400 μg of FA from supplements and fortified food (SACN 2008).

Fortifying flour, on the other hand, has been greatly successful at preventing

neural tube defects. These are the results of a meta-analysis of 8 studies

looking at the effect of national folic acid fortification programs on the

prevention of neural tube defects. Reductions due to fortification ranged from a

31% to 78%. Overall, there was a 46% reduction in the risk of neural tube

defects with folic-acid fortification.

Fortification is successful partly because it does not require women to change

their habits. Women who eat fortified foods increase their folic acid intake even

if they are not planning a pregnancy.

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Here is another study on the effectiveness of fortifying flour with folic acid. We

assume this child is thinking: “Thanks for fortifying my mom’s flour.” But while

these numbers are impressive, this is only 9% of the birth defects that might

have been prevented through flour fortification.

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So we know that fortification effectively improves iron status and reduces the risk of anemia, which can be debilitating. We know that fortification reduces the risk of neural tube defects. But we also know that a lot of the world’s flour and rice are not yet fortified. So here is what you can do about that.

First, if you are already fortifying, ensure that your internal quality control measures are in place and are followed consistently.

Secondly, compare the amount of type of iron and the amount of iron and folic acid in your premix to the WHO flour fortification recommendations. If your premix has less than the recommended amount or the type of iron you are using is not bioavailable, you’re spending a lot of money on premix that may not be making a health impact. WHO recommendations are not yet available for rice fortification, but we can provide resources to help determine appropriate standards for your country.

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If you are not fortifying, review the technical topics under the “Implement Effectively” section of our website.

Whether your fortification standard needs to be improved, or your country needs to begin fortification, contact FFI, and we can help connect you with other partners in your country to advocate for change.

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For more information, you can contact me directly or the Food Fortification

Initiative through social media. Thank you.

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