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Preventing NTDs With Fortified Flour




                 Presented by Robert J. Baldwin,
                    FFI Public Sector Liaison
                         June 28, 2011
                                                   CS122586
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
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.
Flour Fortification Status
June 2011: Fortifying with at least iron and/or folic acid




 Mandatory

 Planning

 Voluntary

 No Flour Fortification
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
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
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
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
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
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
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
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
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
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
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
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
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
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.

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Ffi 28.6.2011

  • 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.