Revised recommendations for iron fortification of wheat flour and an evaluation of the expected impact of current national wheat flour fortification programs.
BACKGROUND
Iron fortification of wheat flour is widely used as a strategy to combat iron deficiency.


OBJECTIVE
To review recent efficacy studies and update the guidelines for the iron fortification of wheat flour.


METHODS
Efficacy studies with a variety of iron-fortified foods were reviewed to determine the minimum daily amounts of additional iron that have been shown to meaningfully improve iron status in children, adolescents, and women of reproductive age. Recommendations were computed by determining the fortification levels needed to provide these additional quantities of iron each day in three different wheat flour consumption patterns. Current wheat flour iron fortification programs in 78 countries were evaluated.


RESULTS
When average daily consumption of low-extraction (< or = 0.8% ash) wheat flour is 150 to 300 g, it is recommended to add 20 ppm iron as NaFeEDTA, or 30 ppm as dried ferrous sulfate or ferrous fumarate. If sensory changes or cost limits the use of these compounds, electrolytic iron at 60 ppm is the second choice. Corresponding fortification levels were calculated for wheat flour intakes of < 150 g/day and > 300 g/day. Electrolytic iron is not recommended for flour intakes of < 150 g/day. Encapsulated ferrous sulfate or fumarate can be added at the same concentrations as the non-encapsulated compounds. For high-extraction wheat flour (> 0.8% ash), NaFeEDTA is the only iron compound recommended. Only nine national programs (Argentina, Chile, Egypt, Iran, Jordan, Lebanon, Syria, Turkmenistan, and Uruguay) were judged likely to have a significant positive impact on iron status if coverage is optimized. Most countries use non-recommended, low-bioavailability, atomized, reduced or hydrogen-reduced iron powders.


CONCLUSIONS
Most current iron fortification programs are likely to be ineffective. Legislation needs updating in many countries so that flour is fortified with adequate levels of the recommended iron compounds.
Hurrell
Richard
R
Swiss Federal Institute of Technology (ETH), Institute of Food Science and Nutrition, ETH Zentrum, LFV D20, Schmelzbergstrasse 7, 8092 Zürich, Switzerland. Richard.hurrell@ilw.agrl.ethz.ch
Ranum
Peter
P
de Pee
Saskia
S
Biebinger
Ralf
R
Hulthen
Lena
L
Johnson
Quentin
Q
Lynch
Sean
S
D000293:Adolescent; D000328:Adult; D018798:Anemia, Iron-Deficiency / Q000517:prevention & control; D002648:Child; D004032:Diet; D005069:Evaluation Studies as Topic; D005260:Female; D005433:Flour / Q000032:analysis*; D005527:Food, Fortified / Q000592:standards*; D017408:Guidelines as Topic; D006801:Humans; D038622:Internationality; D007501:Iron / Q000008:administration & dosage* / Q000737:chemistry; D058085:Iron Compounds / Q000008:administration & dosage / Q000493:pharmacokinetics; D000090463:Iron Deficiencies; D008297:Male; D018673:Nutrition Policy / Q000639:trends*; D009752:Nutritional Status; D014908:Triticum; D055815:Young Adult
D058085:Iron Compounds; D007501:Iron