e-Library of Evidence for Nutrition Actions (eLENA)


An online library of evidence-informed guidelines for nutrition interventions and single point of reference for the latest nutrition guidelines, recommendations and related information.

Alternate Text All interventions

Fortification of wheat flour

Intervention | Last updated: 15 May 2023

Fortification is the practice of deliberately increasing the content of an essential micronutrient, i.e. vitamins and minerals (including trace elements) in a food, so as to improve the nutritional quality of the food supply and provide a public health benefit with minimal risk to health.

Wheat is an important cereal crop and together with maize and rice account for 94% of total cereal consumption worldwide. Fortification of industrially processed wheat flour, when appropriately implemented, is an effective, simple, and inexpensive strategy for supplying vitamins and minerals to the diets of large segments of the world’s population.

WHO Recommendations

Wheat flour fortification should be considered when industrially produced flour is regularly consumed by large population groups in a country.

Decisions about which nutrients to add and the appropriate amounts to add should be based on a number of factors including i) the nutritional needs and deficiencies of the population; ii) the usual consumption profile of “fortifiable” flour (i.e. the total estimated amount of flour milled by industrial roller mills, produced domestically or imported, which could in principle be fortified); iii) sensory and physical effects of the added nutrients on flour and flour products; iv) fortification of other food vehicles; and v) costs.



Evidence

Related Cochrane reviews

Fortification of wheat and maize flour with folic acid for population health outcomes

Centeno Tablante E, Pachón H, Guetterman HM, Finkelstein JL. Cochrane Database of Systematic Reviews. 2019; Issue 7. Art. No.: CD012150.

Fortification of staple foods with vitamin A for preventing vitamin A deficiency (protocol)

Hombali AS, Venkatesh BT, Nair S, Peña-Rosas JP. Cochrane Database of Systematic Reviews. 2012; Issue 9. Art. No.: CD010068. (Update has been submitted for publication)

Fortification of staple foods with zinc for improving zinc status and other health outcomes in the general population

Shah D, Sachdev HS, Gera T, De-Regil LM, Peña-Rosas JP.Cochrane Database of Systematic Reviews 2016, Issue 6. Art. No.: CD010697.

Summary of this review Alternate Text

Wheat flour fortification with iron for reducing anaemia and improving iron status in populations

Field MS, Mithra P, Estevez D, Peña-Rosas JP. Cochrane Database of Systematic Reviews. 2020; Issue 7. Art. No.: CD011302.

Other related systematic reviews

Global birth prevalence of spina bifida by folic acid fortification status: a systematic review and meta-analysis

Atta CA, Fiest KM, Frolkis AD, Jette N, Pringsheim T, St Germaine-Smith C et al. Am J Public Health. 2016;106:e24–34.

Micronutrient fortification of food and its impact on woman and child health: a systematic review

Das JK, Salam RA, Kumar R, Bhutta ZA. Syst Rev 2013;2:67–93.

Effect of iron-fortified foods on hematologic and biological outcomes: systematic review of randomized controlled trials

Gera T, Sachdev H, Boy E. Am J Clin Nutr. 2012;96:309–24.

Evidence of the effectiveness of flour fortification programs on iron status and anemia: a systematic review

Pachón H, Spohrer R, Mei Z, Serdula MK. Nutrition Reviews. 2015; 73(11):780-95.

Cost-effectiveness Learn More Alternate Text

Cost-effectiveness analyses

Decline in the prevalence of neural tube defects following folic acid fortification and its cost-benefit in South Africa

Sayed AR, Bourne D, Pattinson R, Nixon J, Henderson B. Birth Defects Res A Clin Mol Teratol. 2008; 82(4):211-6.

Cost-effectiveness of mandatory folate fortification v. other options for the prevention of neural tube defects: results from Australia and New Zealand

Dalziel K, Segal L, Katz R. Public Health Nutr. 2010; 13(4):566-78.

Cost-effectiveness of a folic acid fortification program in Chile

Llanos A, Hertrampf E, Cortes F, Pardo A, Grosse SD, Uauy R. Health Policy. 2007; 83(2-3):295-303.

Cost effectiveness analysis of strategies for child health in developing countries

Edejer TT, Aikins M, Black R, Wolfson L, Hutubessy R, Evans DB. BMJ. 2005; 331(7526):1177.

A strategic approach to the unfinished fortification agenda: Feasibility, costs, and cost-effectiveness analysis of fortification programs in 48 countries

Fiedler JL, Macdonald B. Food Nutr Bull. 2009; 30(4):283-316.

Retrospective Assessment of Cost Savings From Prevention

Grosse SD, Berry RJ, Mick Tilford J, Kucik JE, Waitzman NJ. Am J Prev Med. 2016; 50(5 Suppl 1):S74-S80.

Reevaluating the Benefits of Folic Acid Fortification in the United States: Economic Analysis, Regulation, and Public Health

Grosse SD, Waitzman NJ, Romano PS, Mulinare J. Am J Public Health. 2005; 95(11):1917-22.

Iron fortification and iron supplementation are cost-effective interventions to reduce iron deficiency in four subregions of the world

Baltussen R, Knai C, Sharan M. J Nutr. 2004; 134(10):2678-84.

Category 2 intervention

Systematic review(s) have been conducted but no recent guidelines yet available that have been approved by the WHO Guidelines Review Committee

Learn More Alternate Text

Essential Nutrition Actions

This intervention is an Essential Nutrition Action targeting the first 1000 days of life.

Learn More Alternate Text

Biological, behavioural and contextual rationale

Fortification of wheat flour