PROJECT PRESENTATION FOOD FORTIFICATION
FORTIFYING FLOUR WITH FOLIC ACID TO PREVENT NEURAL TUBE DEFECTS(NTD)
WHAT IS FOOD FORTIFICATION? Food fortification is defined by the World Health Organization (WHO): as the practice of deliberately increasing the content of essential micronutrients vitamins and minerals in a food so as to improve the nutritional quality of the food supply and to provide a public health benefit with minimal risk to health (1) In developing countries, the objective is clearly to fortify foods that are consumed by the overall population ( mass fortification ) and especially its poorest component in order to increase the health and wealth of the people, resulting in a more productive workforce and a decreased burden on healthcare systems. (1) WHO, The role of food fortification in the control of micronutrient malnutrition, p.24
WHAT ARE FOLATE / FOLIC ACID? Folate, also quoted as dietary folate (DF), is a B group vitamin needed for healthy growth and development, especially of the nervous system. This vitamin is known as folate when occurring naturally in food, such as green leafy vegetables (broccoli, spinach, collard ), lentils, dried beans and peas, citrus fruit and natural orange juice. Folic acid is the synthetic form used in supplements and fortification. It is more readily absorbed than naturally-occurring folate. Both forms are also known as vitamin B9.
IS FOOD FORTIFICATION THE ONLY WAY TO PROVIDE FOLIC ACID TO POPULATIONS? Another vehicle exists: the supplementation. It refers to the use of iron-folate supplements in the form of pills or powders. In the case of folic acid supplements, it must be taken daily when women begin trying to conceive. In developing countries, such recommendation is difficult to implement because: the pregnancies are not planned, basic information is generally missing and the access to supplements is limited due to availability or cost.
A NTD is a type of birth defect affecting the brain and spinal cord. The neural tube forms within 28 days after conception and develops into the brain and spine. NTDs occur when the neural tube fails to close properly, which can result in neural tissue being exposed and susceptible to damage. FOOD FORTIFICATION WHAT ARE NEURAL TUBE DEFECTS (NTDS)? (2) Types of NTDs include spina bifida and encephalocele which can lead to permanent disability and anencephaly which always causes death. (2) Food Fortification initiative (FFI), Fortifying flour with folic acid to prevent neural tube defects, Atlanta, USA:2012;
WHY IS VITAMIN B9 SO IMPORTANT? Human body needs vitamin B9 (thus folic acid) to make normal red blood cells. It is essential for the production, repair and functioning of DNA, our genetic map. White blood cells are also affected impairing immune functioning. Pregnant women have an increased need for folic acid to support the growth of the placenta and fetus and prevent certain birth defects. If folate/folic acid is not present in adequate amounts during the first weeks of fetal development, DNA required for the development of a child s neural tube cannot be formed leading to an open spine (spina bifida), an open skull (encephalocele) or a lack of brain (anencephaly) (3) Consequently, folic acid is important for the health development of babies in early pregnancy. A baby s growth is the most important in the first weeks of life, often before a woman is aware she is pregnant. The neural tube closes very early in pregnancy; if it doesn t close, the result is a Neural Tube Defect (NTDs). (3) Project Health Children (PHC), Overview of Folic Acid/Folate, p.5;
WHY USING THE FORTIFICATION OF FLOUR TO FIGHT NTDS? Fortification of flour (wheat and maize) with folic acid has a proven record of prevention of NTDs in developed countries as attested by scientific research and experimentation. It explains why, in countries like the United States (4), Canada, Australia, the wheat fortification with folic acid is mandatory. We consider that every year 320.000 children born with severe defects due to maternal folate deficiency. To prevent NTDs for all pregnancies, planned and unplanned, the World Health Organization (WHO) recommends that women capable of becoming pregnant consume 0,4 mg (400 µg) of folic acid per each day (5). (4) Flour fortification in the United States is mandatory since January 1st, 1998; (5) http///www.searo.who.int/linkfiles/nutrition_for_health_and_development_who_weekly_iron_folic_acid.pdf
WHY USING THE FORTIFICATION OF FLOUR TO FIGHT NTDS? Most recommend that women take a supplement of folic acid periconceptionally (usually for at least one month prior to conception and during the first three months of pregnancy). But consuming the equivalent of 0,4 mg (400 µg) of vitamin B9 daily through a normal alimentation is quite difficult, especially in developing countries. Consequently, increasing levels of folic acid in staple foods through fortification increases the likelihood that the target population will receive adequate amounts of folic acid needed to prevent NTDs (6). Medical studies reports that women who take the recommended daily dose of folic acid as stated reduce their baby s risk of NTDs by 50 to 70%. (6) Berry RJ, Mulinare J, Hammer HC, Folic acid fortification: neural tube defect risk reduction a global perspective. In Bailey LB, Folate in health and disease, 2010;
WHAT MAKES (FLOUR) FORTIFICATION SO IMPORTANT FOR AFRICA? Though grain fortification is promoted around the world, the initiative is especially worthwhile in Africa for different reasons: The health infrastructure is not well advanced, especially outside the major cities; Antenatal care is not always accessed in a timely manner due to a surprise pregnancy, associated costs and/or local customs; Some cultural or religious beliefs give people the impression that children with birth defects are cursed or bad omens. This can lead to negative treatment of the affected children and their families within a community; ( 7 ) (7) Fortify grains to prevent Neural Tube defects in Africa Advocacy toolkit, p.5;
HOW TO IMPLEMENT A FLOUR FORTIFICATION POLICY? FOOD FORTIFICATION Flour Fortification is mandatory in more than 70 countries worldwide. These countries experienced between 31 and 58% reductions in NTDs. Evidence have shown no significant effect on increased risk of cancer, cognitive decline related to B12 deficiency nor childhood asthma. (8) In those countries, all wheat flour imported or milled for making bread must contain the required amount of folic acid as required by the law setting the mandatory fortification standards. In some other countries, flour fortification can be done on a voluntary basis. Then, the manufacturer or importer can choose what vitamins and minerals he wants to add, providing they are permitted by the local rules. A voluntary flour fortification can be consider as a risky program for the players as they lose their competitive edge and market shares over those who refrain from participation. (8) FFI, op.cit.
WHAT IS THE SITUATION IN ANGOLA? No legislation exists regarding food fortification in Angola. This means that importers / producers can improve the nutritional value of food on a voluntary basis. Most of the wheat flour is imported. (9) Available statistics on NTD s are rare. The only available ones are figures calculated by March of Dimes, an American non-profit association. They assess the number of NTD s are 20/10.000. (10) FFI considers that with folic acid policy in place, the birth prevalence of neural defects would be about 6 per 10.000 (9) 372.308 Metric tons imported in 2010 (FAO data) ; (10) March of Dimes, www.marchofdimes.org, statistics 8 March 2012;
WHAT IS THE SITUATION IN ANGOLA? Anemia, another common disease in Angola caused by nutritional deficiencies, can also been reduced by the fortification of flour. As per WHO statistics (11), the percentages are : Anemia in non-pregnant women of reproductive age is 44%; Anemia in pre-school children is 52% Population at risk of inadequate zinc intake is 24,4% ( 11) WHO, The global prevalence of anemia in 2011, Geneva: World Health Organization, 2015;
WHY FORTIFY FLOUR? FOOD FORTIFICATION Many vitamins and minerals contained in flour, like iron and vitamin B9 are lost when bran and germ are separated during the refinement process. Moreover, the vitamins and minerals found in flour are not naturally highly bioavailable, meaning that they are not usually available for absorptions by humans. Flour is consumed all over the world in a wide range of popular forms such as bread, bagels, tortilla, pasta It is relatively inexpensive, consumed by a large part of the population. Vitamins and minerals can be added in the form of a premix giving a homogenous product, what is not possible with a more granular food product.
WHAT IS EFFA S PROJECT? FOOD FORTIFICATION Whereas fortification of wheat flours with zinc and folic acid has a proven record of prevention of NTDs in developed countries, Angola has few, if any, sources of folic acid unlike developed countries which have folic acid available from ready-to-eat cereals, (12) Angola has not implemented any mandatory policy in terms of food fortification and no alternative options exist for the moment, the potential risk of NTD s remains high in the country, We, EFFA are prepared to bring all support for the implementation of a mandatory policy of grain flours fortification in Angola according to internationally accepted criteria and applied by countries that have adopted a public policy in this matter. (12) Berry (Robert J.), Bailey (L), Mulinare (J) & Bower C, Fortification of flour with folic acid, in Food fortification Bulletin, vol.31, n 1, 2010, p.51;
WHAT IS EFFA S PROJECT? FOOD FORTIFICATION We, EFFA, propose to present the project to: The Angolan Health Authorities and any local parties who could be involved in this project providing them with all the necessary and scientific information in order to get their support. In this respect, EFFA could invite an International expert in food fortification for a conference in Luanda We, EFFA, propose to support the local Authorities who will endorse the project, acting in accordance with the social values of a nonprofit Association promoting the improvement of the public health in Angola.
For the time taken to read through our presentation. We are looking forward to your support for implementation of this project Do not hesitate to contact us with your suggestions and/or questions Contact: info@effaangola.org Website: www.effaangola.org