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A fortifying force? by Stephanie Santana, FFI Graduate Research Assistant, Emory University

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lobally, 85 countries require millers to fortify their flour with nutrients such as iron, riboflavin, folic acid, zinc, vitamin B12 and vitamin A. These nutrients have a range of benefits from assisting in cognitive development to strengthening immune systems. A lesser-used mineral with its own set of unique benefits is calcium. However, the United Kingdom is one of the few countries that add it to flour. How did this happen and what results has it yielded? Anticipating a reduction in dairy products because of World War II, the United Kingdom enforced the fortification of flour with calcium carbonate during the early 1940s. A possible concern may have been the increased risk of rickets, which can be caused by a deficiency of calcium, Vitamin D, or phosphate and result in weakened bones. One of the companies following the mandate is Wessex Mill located in Oxfordshire, England. “It was decided after WWII that white flour should have the same nutritional properties as wholemeal flour to boost the health of the population by providing them with vitamins through their bread,” said Emily Munsey, a Trainee Mill Manager at Wessex Mill. Today, millers are also required to include iron, thiamine (Vitamin B1), and nicotinic acid.

Can calcium boost the health of a population?

Young children are encouraged to drink milk to develop strong bones and pearly white teeth. It is the most abundant mineral within a human body, and calcium remains as equally important to adults. According to the United States National Institutes of Health, the mineral is necessary for performing key tasks, such as the transmission of nerve messages, muscle function, or blood clotting. Furthermore, a lack of calcium may lead to an increased risk of osteoporosis. Humans do not produce calcium themselves. We must consume it, and luckily, many foods offer it naturally. Those include cabbage, kale, broccoli, almonds, yogurt, cheese, and of course, milk. In fact, the World Health Organization (WHO) states that dairy products make up 50-80 percent of dietary calcium for most industrialized countries. However, what if someone is allergic to dairy or what if dairy products were scarce in a region? Well, fortified flour can be that steady alternative to maintain adequate calcium levels. 44 | February 2017 - Milling and Grain

Based on North American and Western European data, the WHO’s recommended daily calcium allowance for adults ranges from 1000-1300 mg/day. The values vary depending on a person’s gender, age, and pregnancy status. To measure if a person is actually getting enough calcium, the UK measures intake levels. However, there is no universally agreed-upon cutoff to define deficiency1. In 1981, a committee within the UK’s Scientific Advisory Committee on Nutrition (SACN) reported that flour fortification should no longer be mandatory. But in 1998, that same committee suggested that calcium fortification of flour be maintained over concern of intakes falling below a certain level. In a 2012 report, SACN affirmed that removing calcium from flour would “decrease population intakes of calcium and increase the proportion with intakes below the LRNI (lower reference nutrient intake)”. SACN says this may lead to an increased risk in calcium deficiency, especially for women and low-income groups.

Why do so few countries fortify flour with calcium?

One factor may be that the prevalence of deficiency is just not available in most countries, according to the WHO. Countries can measure bone resorption in urine or plasma, but it is a costly method2. Other reasons may include the challenges of adding calcium. According to Annette Bueter of Mühlenchemie, a German-based premix provider, calcium carbonate can interact with humidity in an acidic environment and produce carbon dioxide. Because carbon dioxide is a gas, it may cause the bags to burst. Quentin Johnson, Training and Technical Support Coordinator of the Food Fortification Initiative (FFI), adds that flow ability, quantity and cost may also be an issue, and “Calcium carbonate and calcium sulphate are not very free flowing, which can cause feeder problems and inconsistency of addition rate.” Johnson says that the levels of calcium are much higher than other minerals, such as iron and zinc. For example, the UK requires 235 - 390 mg calcium per 100 g of flour while it requires not more than 1.65 mg of iron per 100 grams of flour. The typical cost for calcium may also be a limiting factor. Calcium carbonate is about $.50 per kg while calcium sulphate, an alternative form, fetches a price tag of about $1.00 per kg. Jordan fortifies wheat flour with calcium, along with 10 other vitamins and minerals. Cost is not an issue for millers because the Ministry of Health procures the premix and distributes it to all the mills at no cost, said Nicolas Tsikhlakis, Chief Operating Officer and Partner of Modern Flour Mills and Macaroni Factories Co. in Amman, Jordan.