1. Preventing NTDs With Fortified Flour
Presented by Robert J. Baldwin,
FFI Public Sector Liaison
June 28, 2011
CS122586

2. What is Flour Fortification?
Fortification is adding
vitamins and
minerals to flour
during the milling
process so that
staple foods are
more nutritious.
Modern mill with three feeder lines

3. FFI Network
FFI is network of partners
working together to make flour
fortification standard milling
practice so that people
worldwide are smarter, stronger
and healthier.

4. Flour Fortification Status
June 2011: Fortifying with at least iron and/or folic acid
Mandatory
Planning
Voluntary
No Flour Fortification

5. Highlight Success
Celebrate!
15 Years
Of fortifying flour with folic acid
Thousands
Of birth defects prevented every year
Millions
Of healthcare dollars saved annually
www.FFInetwork.org

6. Success: Oman NTD Reductions
Spina bifida and birth outcome before and after fortification of flour with iron and folic acid in Oman
D. Alasfoor, M.KI. Elsayed and A.J. Mohammed

7. Success: Global NTD Reductions
18
15.8 17.0
16
14
-37% - 46% 14.1
12 10.8
- 35% - 41% - 31%
Neural tube 10 8.6 9.7 10.1
birth defects 8
9.8
6.6
per 10,000 6.3
6
live births
4
2
0
USA
Canada
1998 Costa Rica
1998 Chile
1998 South Africa
2000
2003
Before fortification After fortification
Centers for Disease Control and Prevention , “Folic Acid in the Prevention of Birth Defects”
Public Health Grand Rounds, February 18, 2010

8. Success: Healthcare Savings From
Preventing Spina Bifida
Chile $1 spent
$12 saved
United States $1 spent
$48 saved
South Africa 1 rand spent
30 rand saved

9. One:
Understand Limits of Supplementation
• Limited population coverage
• Costly
• Is it sustainable as government distribution program?
• Compliance - often forgotten
• Frequently not taken before conception
• Not taken if pregnancy is not planned

10. Two:
Understand Limits of Folate Intake
From Daily Diet
• Unstable in cooking
• To get 400 micrograms of folate a day, eat:
o 4 slices of fried beef liver or
o 44½ medium ripe tomatoes or
o 14½ cups of raw broccoli or
o 17½ cups of orange juice or
o 19½ cups of raw green beans or
o 5½ cups of black beans or
o 200 medium red apples
Source: US Centers for Disease Control and Prevention
http://www.cdc.gov/about/grand-rounds/archives/2010/02-February.htm

11. Three:
Understand Benefits of Flour
Fortification
• Most efficient means of delivering folic acid to the
greatest number of people
• Cost effective
• Improves folic acid stores before conception

12. Four:
Be Prepared for Criticism of Flour
Fortification
• Claims that it medicates food
• Not natural - genetically modifying food
• Nanny state
• Eliminates free choice
• Excessive folic acid could cause harm

13. Five:
Arm yourself with data
• Effectiveness of fortifying flour globally
• Cost to fortify (US$2 - $3 per metric tonne of flour)
• Healthcare savings
• NTD rates
• Folate status
• Number of abortions due to NTD diagnosis
• Average cost of treating child with spina bifida

14. Six:
Partner With Other Sectors
• Identify champions
• Look outside the healthcare sector
• Identify benefits to other sectors
• Recognize your bias
• Establish a national fortification alliance

15. Seven:
Support Mandatory Fortification
• For Millers:
o Equalizes costs
• For Consumers:
o Delivers health benefits equitably
• For Economists:
o Improves productivity and saves health care
expenditures
• For Regulatory Staff:
o Simplifies compliance testing

16. Eight:
Advocate Fortifying Flour, Not Bread
• Technology for flour fortification is readily available
• Milling is a centralized process
Flour mill in Turkmenistan. Photo courtesy of UNICEF

17. Nine:
Prepare for the Media
• Identify a media spokesman
• Proactively suggest stories to media
Ten:
Educate Elected Officials and Policy
Makers
• As governments change, newly elected officials need to
be educated about fortification’s value
17

18. For More Information
Sheep blocking a road
on the South Island in
New Zealand
symbolize the
roadblocks faced in
attempting to
implement mandatory
flour fortification in
Ireland and New
Zealand.