Micronutrient Deficiencies: A Lingering Global Health Crisis
In 2004, the Micronutrient Initiative (MI) and UNICEF jointly released a report that underscored the pressing issue of vitamin and mineral deficiencies as one of the most significant public health challenges of our time. Shockingly, nearly two decades later, this sobering reality persists. Micronutrient deficiencies continue to afflict a staggering 3 billion individuals, causing severe and enduring health problems. Malnutrition, an unfortunate consequence of nutrient deficiencies, underpins 45 percent of child mortality, according to the 2022 data from the Micronutrient Forum. Furthermore, statistics from the World Health Organization (WHO) reveal that a distressing 155 million children experience stunted growth each year, both physically and cognitively, while one-third of women of reproductive age suffer from anemia, including 40 percent of pregnant women, due to nutritional deficiencies.
The Crucial Role of Grain Flour Enrichment
Grain flour serves as the cornerstone of diets in countless societies worldwide, comprising not only the staple food but also a foundation for numerous value-added baked products. Approximately 79% of the global population, approximately 6.3 billion people, rely on grains as their primary dietary source. This includes cereals such as rice, wheat, maize (corn), millet, and sorghum, as outlined by the WHO. Regrettably, modern flour production methods strip grains of essential nutrients, exacerbating the risk of malnutrition. The flour-making process typically entails the removal of two integral parts, the bran and the germ, leaving behind only the endosperm, which is then ground into fine powder. This extraction significantly diminishes the nutritional value of the flour, as it eliminates a substantial portion of thiamin, riboflavin, niacin, vitamin B-6, folic acid, and iron present in whole grains.
Moreover, once the endosperm is isolated, it undergoes further grinding into a fine powder and a chemical bleaching process to achieve a whiter appearance, often involving chlorine or benzoyl peroxide. Unfortunately, this bleaching step results in the destruction of many original nutrients, further diminishing the flour’s nutritional quality. To counteract this loss of nutrients incurred during milling, the practice of flour enrichment comes into play. Enrichment is the process through which the critical nutrients lost during milling are reintroduced in quantities comparable to those lost during processing.
A Historical Perspective
The concept of flour enrichment has its roots in the 1920s when Benjamin R. Jacobs, a renowned biochemist, documented the loss of essential nutrients during cereal and grain processing. Studies indicate that the first successful flour enrichment took place in 1935 when chemist Robert R. Williams pioneered a method to synthesize thiamin and vitamin B. In the early 19th century, America grappled with high deficiencies in vitamin B and thiamin, leading to approximately 17,000 deaths attributed to beriberi and pellagra in 1928. This crisis fueled the momentum for flour enrichment we witness today.
In 1998, the FDA mandated the fortification of enriched grain foods with folic acid to combat neural tube defects (NTDs). Public health studies subsequently reported a 23 percent reduction in NTD incidence in the U.S. and a 54 percent decrease in Nova Scotia, Canada, directly attributed to the presence of folic acid in flour. Dr. Magda Aguiar, the project director of a study published in August 2019 in the European Journal of Clinical Nutrition, highlighted the economic benefits of mandatory flour enrichment. She emphasized that the British National Health Service would incur an additional cost of £65 million (US$80 million) without mandatory flour enrichment, whereas the cost of such enrichment would be negligible, at just 12 pence per person annually.
The Global Embrace of Flour Enrichment
Recognizing the benefits associated with mandatory flour enrichment, an increasing number of countries worldwide have adopted measures to alleviate the health burden. As of 2023, 92 countries have legislation mandating the fortification of at least one industrially milled cereal grain. Of these, 91 countries require the fortification of wheat flour either individually or in combination with other grains, while Papua New Guinea mandates rice fortification alone.
In the United States, nearly 95 percent of white flour is enriched with iron and four essential B vitamins: thiamin, niacin, riboflavin, and folic acid. The U.S. FDA stipulates specific quantities of these nutrients to qualify, ensuring that enriched flour effectively combats nutrient deficiencies in populations reliant on refined grains.
Enrichment Reshapes Whole-Grain Offerings
Over the last decade, consumer demand for whole-grain products has surged due to the well-documented health benefits associated with their consumption. This includes the prevention of cardiovascular diseases, certain cancers such as colon cancer, reduced risk of type-2 diabetes, and their prebiotic potential. Brian Strouts, Vice-President of Baking and Food Technical Services at AIB International, observes, “There is substantial consumer acceptance, and whole grains come with minerals, antioxidants, vitamins — all of which are easy to promote as healthier.” However, incorporating whole grains into bakery formulations poses challenges, affecting factors like shelf life, color, flavor, and texture.
One of the primary issues bakers encounter when using whole wheat flour is a lack of volume in the final product. Dough may not rise adequately, resulting in dense loaves. Some researchers posit that the bran flakes and germ in whole wheat flour act like small razors, shredding gluten strands in the dough, impeding gluten development. By enriching flour to match the nutritional content of whole grains, bakers can satisfy health-conscious consumers with high-quality products.
Fortification: A Vital Approach in Africa
While flour enrichment is a rare practice in the African milling industry, fortification has gained prominence as a complementary approach to combat malnutrition. Unlike enrichment, which focuses on restoring the nutrients originally present in grains before milling, fortification takes a broader perspective by adding new micronutrients that are not inherently found in the grains but are lacking in the diets of the target population.
Research has demonstrated that fortifying flour with iron helps protect against anemia, while fortifying with folic acid prevents severe birth defects such as neural tube defects and spina bifida. Moreover, fortifying staples with vitamin A promotes eye health, boosts immune systems, and saves hundreds of thousands of lives annually. The attractiveness of fortification in the African context lies in its ability to effect change without necessitating behavior alterations by consumers, making it possible to reach entire populations, particularly those most in need.
To date, 29 African countries have made flour fortification mandatory, striving to enhance the nutritional well-being of their citizens. Some countries, including the Democratic Republic of Congo, Namibia, Sierra Leone, and Swaziland, voluntarily fortify over half of their industrially milled wheat flour, even though it is not required by law.
Challenges in Fortification Programs
However, national fortification programs in Africa often face challenges stemming from poorly established or inadequately designed protocols, insufficient resources, and a lack of qualified laboratory expertise for product testing. A 2021 study analyzing the micronutrient content of maize procured from the Kenyan market revealed a compliance rate of only 28 percent. Another study in Nigeria found that imported premixes, commercial blends of vitamins and minerals, typically adhered to high-quality standards, while local blends exhibited inconsistent quality, with some falling below standards.
Paving the Way for Effective Flour Fortification in Africa
Efforts are underway to enhance compliance rates and realize the full potential of flour fortification in Africa. Millers For Nutrition, an industry-led coalition, is spearheading this initiative, aiming to assist millers in producing fortified staple foods and reaching one billion people with fortified rice, edible oil, and flour by 2026. The coalition is currently implementing programs in eight countries across Africa and Asia: Bangladesh, Ethiopia, India, Indonesia, Kenya, Nigeria, Pakistan, and Tanzania.
Several challenges have been identified by the coalition, including insufficient government enforcement and limited consumer demand, which often reduce millers’ incentive to fortify their products. Additionally, establishing fortification procedures and maintaining consistent fortification requires significant investments in equipment, premixes, staff training, and management time.
To address these challenges, the coalition seeks to create incentives and capabilities for millers to comply with regulations and voluntary standards effectively. Millers joining Millers for Nutrition and committing to improving the nutritional quality of their products will receive free technical support, including tailored training, business advice, product testing, and access to online tools and resources. High-quality premixes have been a significant barrier to compliance, and the coalition has enlisted various stakeholders across the food fortification value chain, including founding partners BASF, DSM-Firmenich, Mühlenchemie/SternVitamin, Piramal, BioAnalyt, and Sanku. These partners will contribute technical expertise and support to ensure high compliance levels.
Sanku, in particular, is an expert in working with small and medium-sized millers. This non-profit organization installs small machines called dosifiers, which add essential nutrients like vitamin B12, zinc, folic acid, and iron to flour produced by local millers. To date, Sanku has provided over 800 dosifiers to more than 750 mills in Tanzania, Kenya, Rwanda, Malawi, and Mozambique, where malnutrition is prevalent.
Ambitious Goals and Tangible Results
The coalition has set ambitious goals, aiming to ensure adequate and sustained fortification of 85 percent of selected industrially processed staple foods. Encouragingly, the framework on which the coalition is based has already achieved some level of success. The coalition highlights the Millers Fortification Index, which was introduced to acknowledge millers’ fortification efforts in Kenya. Since its launch in 2018, compliance with wheat flour fortification has risen from 51 percent in 2018 to 70 percent in 2022. A similar trend is observed in maize flour, with compliance rates increasing from 28 percent in 2018 to 49 percent in 2022. This success underscores the potential for compliance rates to rise significantly across the African continent.
This feature appeared in ISSUE 6 of MILLING MIDDLE EAST & AFRICA MAGAZINE. You can read this and the entire magazine HERE
