August 1984 - United States Agency for International ...pdf.usaid.gov/pdf_docs/pdwae276.pdfmeal with ferrous sulfate added to it. I . have talked with the US supplier of the premix

Rooom4300Auditors Bldg

August 6 1984

Ms Francesca Nelson Nutrition Officer USAIDKingstonAgency for International DevelopmentWashington D C 20523

Dear Francesca

Enclosed is a copy of the Final Report on Iron Fortification of Corn Meal andWheat Flour inJamaica We hope itwill he a significant factor contributingto activites that result inan iron fortification program inJamaica

Were the suggestions regarding the questionnaire for the corn meal consumptionsurvey helpful We believe the survey is sorely needed and should be carriedout as soon as possible Did you say you do have the funding to have it done I saw the cable Sam Kahn sent regarding your reqsted actions I believe hisco ments on funding are good Our USDARSSA can provide the technicalassistance for (1)fortification technology (2)product testing (3)nutritioneducation and (4)quality assurance activities to help ensure the developmentof a good iron fortification program I believe the monitoring should becovered by someone else Sams suggestion on this is good Im not sure myselfhow much the monitoring activity can be modified

I hope Seprod Ltd has grasped the idea from our conversations and the reportthat itwould be very helpful if not necessary to have some testing done on cornmeal with ferrous sulfate added to it

I have talked with the US supplier of the premix that Jamaica Flour Mills Ltduses inthe bread flour They are doing their homework about ferrous sulfateand I understand even preparing some of their blend with ferrous sulfate fortesting Also I heard that Jamaica Flour Mills Ltd has contacted thesupplier and asked that the next shipment of premix be formulated with ferrous sulfate In it

Do you have a graceful way of finding out from the company such as fromCyrilVassel if this is correct Also he might provide some information on theirthoughts or actions concerning the iron source for the fortification of thecounter-flour when they start production later

Any and all of these activities indicate agood start toward a valuable nroiet and subsequently a successful fortification program

Iwould greatly welcome hearing from you periodically ontheprogresstoward aniron fortification program

Fred F Barrett PhD Food Technologist Nutrition amp Agribusiness Group

cc N Luykx STN SKahn STN

Enclosure AS

IRON-FORTIFICATION OF CORNMEAL ANDIWHEAT FLOUR

IN JAMAICA

REPORT

Dr IJimes took UniVersity Of Kansas Medical -Cenlter

and

Dr Fred Barrett US Department of Agriculture

This report prepared in cooperationwith

Office of Population Health Nutrition USAIDKingston

Office of Nutrition AIDWashington

Office of International Cooperation amp Development US-Department of Agriculture

International Center to Control Nutritional Anemia(ICCNA)Yi Universityof Kansas Medical Center

CONTENTS

I BACKGROUND-

II FOOD FORTIFICATION

III IRON FORTIFICATION PROGRAM- JAMAICA

A Wheat Flour

B Corn Meal

C- Monitoring

D Quality Assurance

E Nutrition Education

F Safety of Fortification

IV ADDITIONAL INFORMATION NEEDED

A Corn Meal Consumption Data

B Response to Added Iron

C Quality of Corn Meal withAddedIron-

D Quality of Counter-Flour with Added Iron

E Addition of Ferrous Sulfate toBakery Flour

V RECOMMENDATIONS AND SUGGESTIONS

APPENDICES

A Estimated Budget

B People Contacted

C Workshop Outline

I BACKGROUND

Discussions between UASIDJamaica the Ministry of Health-GOJ and the Caribbean

Food and NutritiDn Institute (CFNI) about how to combat anemia inJamaica by proshy

viding more iron to target-groups as well as the general population resulted in

the decision to obtain technical assistanceregarding the fortificationof foods

and for helping to develop a program for the iron fortification of cereal foods

in Jamaica

The authors visited Jamaica to provide that assistance by carrying outa feasishy

bility study andoutlininga program for (1) the iron fortification of corn

meal (2)the addition of iron and B-vitamins to counter-flour and (3)changing

the iron source used in the present enrichiment of bread flour to one with

improved bioavail ability properties

The current conditionsfrom which this feasibility studyand program suggestions

were developed~are

1 All bread (wheat) -flour is produced in Jamaica -Itcontains addedironof a

type which isnot readily absorbed by the body It also contains added B-shy

vitamins This flour isused inthe commercial production of all-typesof

bakery foods It isnot used inthe homebythe general population

2 Counter-flour (all-purpose or family flour) iswheat flour whichis

imported Itdoes not contain any added iron or other nutrients This

flour isconsumed by the majority of the population through every-day -use

3 All corn meal is produced inthe country Itis the principalweaningfood

for infants Also it isused as a breakfast food by therest of the family

Cornmeal is recognized as a staple food of the people inthe lower socio-I

economic group The standard market corn meal has no iron or vitamins added

to it

2

This report is the result of that visit

One purposeof the visit was to discussthe advisability of fortifying cornmeal with iron in Jamaica The justification for consideringthis -intervention strashy

tegy to combat iron deficiency stemsfrom the high prevalence of anemia that

has been observed repeatedly instudies conducted in-this countryduring theshy

past two decades A detailed monograph together with a reviewof availableshy

survey information and a discussion of a variety of strategies to combat iron

deficiency was published in 1982by CFNI This report indicates that vi rtuai ly

all surveys of anemia during the past 15 years in infants childrenand

pregnant or lactating women have shown prevalence of anemia varying from 35 to

80 based on current WHO criteria The survey published by McGregor (1974)

which was conducted in 300 infants during the late 1960s is particularly rele

vant to the issue of cornmeal fortification As defined by a hemoglobin conshy

centration-below 11 gdl 76 of infants were anemic at 8 months of age this

prevalence was even higher at 18 months Presumptive evidence was obtained

during this survey that this anemia lresulted from iron deficiency althoughno

specific laboratory measurementswere performed

More recent studies give little or no indication that the prevalence of anemia

is declini An island-wide survey inmore than400 lactatingwomen conducted

by Simmons indicated a Prevalence of anemia of 49based on a hemoglobin level

below12 gdl and aprevalence of 26 using a criteria of 11 gdl During the

first morning ofthis visit reference was made to an ongoingpediatric study in

whichdata on the hemdglobin bullleVels ininfants less than one year of age are

available as a byproduct of the study Based on a hematocrit below 33 which

is roughly equivalent-to WHO criteria of anemia in infants 6- months of age

9

3

the prevalence of anemia ranges from 29 to 47 Unfortunately few ifany of

these surveys have included laboratory measurements that would define iron defishy

ciency as the cause of anemia Similarly no therapeutic trialshave beenco-shy

ducted to demonstrate a hemoglobin response to iron therapy Nevertheless

there islittle reason to doubt that the prevalence of anemia in Jamaicacon-

tinues 1to be high in all susceptible segments of the population and hat iron

deficiency isthe major ifnot only cause of this anemia

One of the major points of discussion during this visit was whether WHO criteria

of anemia based on hemoglobin levels should be applied inthe Jamaican populashy

tion One possible justificationfor employing less stringent criteria is that

on-going genetic studies at the MRC sickle-cell unit at the University of West

Indies have demonstrated a high prevalence of ok-thalassemia intheJamaican

population Brief discussions wereheld with personnel at the sickle-cell unit

at UWI Genetic mapping studies currently being conducted at Oxford insamples collected inJamaica have indicated a prevalence for homozygous ok-thalassemia of

4in ostensibly normal Jamaican childrenwith a frequency of roughly 30 for

heterozygous 4-thalassemia Homozygous -thalassemiais knownto be associated

with a spectrum of hematologic abnormalities comparable to heterozygous Bshy

thalassemia-including mild anemia and microcytosis but no overt tissue iron

loading One can therefore tentatively surmise that q-thalassemia by itself

could not account for the high prevalence of anemia observed inJamaica since

there would bea maximum error due to homozygous-thalassemia of 4 These

considerations do not fully resolve the-question of whether WHO standards of anemia should be applied-to thispopulation Hemoglobinlevels inAmerican

blacks are 05 to 1 gdl lower than inwhites and this is presumably not

accounted for by thalassemia Perhaps themajor implicationofg-thalassemia in

Jamaica isthat neitherhypochromianor microcytosis can be used to assist in

the detection of iron deficient erythropoiesis It shouldbe added thathematoshylogists inthe country agree that sickle cell anemia (SShemoglobin)does not

2)

4

occur with sufficientfrequency to affect the prevalence of anemia since it

occurs in less tha 1 of the population


The fortificationof foods - the addition of selected-nutrients tofoodsin

order toimprovetheir nutritive value - is acommonly used strategy for

improving or maintaining the nutritional status of a population by increasing the

daily intake ofspecific nutrients The technology foradding nutrients to

foods iswell developed and has been used-in many countries for many years Primary examples are the addition of iodine to salt vitamin A to fats and

sugar and vitamin C to juices The most widely used food fortification techshy

nology is for the addition of B-vitamins and iron to cereal foods such as flour

bread meals and pastaL Thefortification of wheat flour with vitamins and iron presently is being used inmore than20 developed and developing countries

Also in at least a dozen countries that do not produce their own flour the

imported flour is required to be fortified with vitamins and mineral s The forshy

tification of foods has been shown to be asimple effective and relatively shy

inexpensive way of introducing nutrients such as bioavailable iron into the

daily diet

The technology for the fortifilcatilon of acereal food such as wheat flour or

cornmeal with iron involves three major components 1 the installI ation andshy

operation of the equipment for adding the nutrient 2 the selectioInof the form

ofnutrient to be used and 3 a decision on the amount of nutrient-to be added to the food inorder to affect a desired daily intake

The crieteria for the selection of a foodas the vehicle forithe added nutrients

usually includes the considerations thatit be consumed (1)by essentiallyall

of the people including the target groups (2)in reasonable amounts (3)ona4

5

fairlyregular basis and (4)by those in the lower economic levels the ones

most in need of the nutrients Since cereal foods are the primary staple food

for so manyof the worlds population especially indevelOping countries they

are the most frequentlyselected vehicles forfortification

In thecaseof JAaica wheatflour and corn meal are -the staple foods of the

population thus are thelogical choices as vehicles for an iron fortification

program- Food forti fication technology already is being used inJamaica for

the enrichment ofwheat (bread) flourandspecial Porn meal withvitamins and

iron Thus nothing further need be written aboutfortification in general

Instead thisreport will focus attention on the task ofincreasing the level of iron

in the Jamaican diet by having ironadded to the counter-flourand standard corn

meal produced in-country The form of iron used to fortify these foods must be

-more availableand utilizablebythebody while at the same time-not produce an

adverse effect on the quality of the foods

III IRON FORTIFICATION PROGRAM AMAICA

inA Wheat Flour - As part of anIiron fortification program for cereal f ods

Jamaica speci fi cat i ons shoul d be established and plans developed with

Jamaica Flour Mills Ltd to ensure-that the form ofiron added to all Wheat

flour produced inthe countrybe ferrous sulfate ifat all possible

Thewheat flour component-of a fort ification program Can be vi ewed both as

1 a radeof the nutritional value the changein iron form used in a

food already part of an intervention and 2as a new nutrition intervention

involving the fortification of counter-flourwith ferrous sulfate and

B-vitamins This intervention will make iron fortified flIou available to

peoplewhqohave not had access tofortified flour

About 45of the flour used in the country is produced inthe Jamaica Flour

Mills Ltd mill inKingston The typeofflour currently produced is used in This flour is notcommerci-al bakeriesto produce breads of all types

available for home use or general consumption Theflour isfortified with

B-vitamins and iron by use of a specially preparedpremixwhichis addedto

the flour using typical food fortification technology This premix contain

enzymes and Oxidation materials inaddition to the vitamins and iron Theso

ingredients are not usually included in standard premixes The form of iroi used in the premix is hydrogn-reduced eemental iron This form of lron i

commonly used to add iron to foods It isa stable form of iron but when

compared to more soluble iron forms such asferrous sulfateits bioavai labi

lity ranks lower-onthescale

It needs to be determined in the case of Jamaica Flour Mills Ltd if the

iron source intheir special premix can be successfully changed to-ferrous

sulfate In-addition to the presence of the other ingredients inthis

premix another factor that warrants attention is that the premix is held

in inventory a relatively long period of time at the mill before it is used

Either or both of these factors could present problems in the reformulation

of the premix to include ferrous sulfate These specific concernsapply

only to thefortification of the bread flour since these other ingredients

will nIot be addedto counter-flour

Although precisecosts are not available at this time preliminary

calculations suggest a sHlight increase incost for premix containing-ferrous

sulfate over one with reduced iron However when related to the use rate

of the premix the difference is about US $000006perpound One would

expect the producer of the flour to absorb that increase -inthe cost as

part of his effort for Improving the nutritional Value of the floIur

7

Tie remaining 55 of the flour used in Jamaica iscounter-flour which

is imported This flour traditionally is used by Ithe majority of the popushy

lation for general home use Available information indicates that this

flour seldom has been fortified withany nutrients including iron sothat

the general population which consumes counter-flour has not been recipients

of anyadded iron intheir daily dietthrough the use of counter flour

Production of counter-flour by Jamaica Flour Mills Ltd isscheduled to

start later this year Plans are to fortify itwith B-vitaMins and iron

The iron source to be added to that flourisunder discussion Ferrous

sulfate isbeing considered asthe iron source ofchoice A premixi for

this use will be much less complicated ingredient-wise-than-that used for

the bread flour It is expected that this premix also will undergo a

long holding time inthe-mill before use but no problems are anticipated

with the use of ferroussulfate Standard premixes containing B-vitamins

and iron as ferrous sulfate (which is the standard for comparison) are

available from producerst of premixes The cost to fortify wheat flour wi th

B-vitamins and iron (ferrousi sulfate) to ci rrent US standards is abo ut US

$00004 per pound The iron levelf for this fortification would be 20 mg

per pound of flour

n review the iron source- contained in the-premixes used to fortify the

heat flour produced in the country should be ferrous sulfate The required

ron IeveI in all wheat- flours shoulld be 20 mg per pound regardlessof iron

1

8

source used Although itlooks feasible to do so effort is underway to

determine thatIt can successfully be done under the production and

marketing methods currently in use without resulting in adeterioration in

product qual ity or Inasignificant increase inthe cost Of theeproducts

Be Corn Meal - All cornmeal marketed in-Jamalca is produced in-coutry The

manufacturer isSeprod Ltd Theyproduce three types of c rnmeal One

type Miracle is degerminated meal which is fortified with vitamins and iron using typical fortification technology Its price is high compared to other

corn meals The iron source usedAcis iron Thelevelof0hydrogen-reduced

the iron and B-vitamins added are at typical levels forifortified corn meal

in other countries

A second type of cornmeal is called IMarigold It is considered a wh61e

kernel meal but ithas a lower fat content as the resultof a small -amount

of the germ being removed during production

The thirdtype of corn meal iscalled Daffodil It is a whole kernel

meal whichI is typically consumed by the majority-of the people It is used

as weaning food for infants porridge for all ftmily members and as an

ingredient along with wheat flour in the preparation of dumplings

Neither of these whole kernel corn-meals-are fortified with iron or

B-vitamin s

Theyearly consumption of Daffodl i1sapproximately20000 tons Figures

are not avai Iable as to how much of this used for children other familly

members and as pet food Such information is needed so that meaningful

levels of iron can be used in corn meal as partof anutrition intervention

program to decrease iron deficiency anemia

9

Corn meal is algical vehicle for carrying additional iron in a nutrition

intervention program because itisthe principal food for children up

to 24 months who represent a ajr target group vulnerabe to1ron defi

ciencyanemia It is reported that there isasmall onsumption of corn

meal bypregnant alctating women In this case a program for the iron

fortification of corn meal would not beconsidered asaninterventionfor

alleviating anemia in-that group

A program for theiron fortification of corn meal would involve the addishy

tion of iron such as ferrous sulfate to the corn meal inthe mill at the

time of production The iron would be blended intoa premix for ease and

accuracy of addition to the meal The level of added iron should be 40 mg

per pound This would provide 10 mg ofiron per day per child basedon

present information that a typical daily feeding Is 4 Oz ofcorn meal

made-up in2 oz portions twice a day in a pint of water This level of

iron equals or slightly exceeds the Jamaica RDA for this age group (7

mgday) This level represents less than half the Jamaican RDA for females

of child-bearing age and for those which are pregnant and lactating-Their

daily iron requirements must be met from other sources

The Daffodil and Marigold brand corn meals would haveonly ironadded to them

Discussions held with nutritionists and public health personnel during this

visit emphasized the point that regular corn meal does not need to be)bull

enriched with B-vitamins or other nutrients Only ironis of concern at

this time for this target group

10

SeprodLtd currently isequipped and has the expertise for the addition of

iron as a premix-tocorn meal by virtue of their experience withenrichin

theMarigold degerminated corn meal

Food fortification programs often involve-the addition of theselected

nutrient to all of a food vehicle produced inthe country However

because of the need for more specific information on the general consumption

of corn meal by all family members a program-of iron fortification ofcorn

meal would best be implemented in stages This would allow for the collecshy

tion of sufficient information on the consumptionof corn meal in the family

across the country (see section on Additional Information Needed) The

first stage of a program would involve the controlled shipment of iron forshy

tified corn meal to specific parishes in one area of Jamaica and regular

corn meal continued innormal distribution to the rest of the country Iron

status datawould be-collected from a randomly sampled population of

children 18-24 months of age both inthe test area receiving fortified meal

and in the control area receiving non-fortified meal These data would

indicate the present iron nutritional status of that target group This

first stage would continue for 18 months at which tiie a follow-up study

would be carried out on another randomly selected group of children two

years of age in both areas The results of this testing would be to

demonstrate the measure of benefit derivedfv= fortified corn meal -andproshy

vide data onwhich to base any necessary changesin the-level of added riron

The cost for adding 40 mg ofironper pound lof corn meal is about-US $0000168

To add 40 mg of iron perpound for the 2O000 tons of corn meal (Daffodil)

used per year would cost approximatelyUS $79400 The manufacturer has

exp ressed agreement to cover this Cost and not have itbe reflected inany

increase in the cost of the corn meal due to the added nutrient Since

SeprodiLtdalready-is-equipped and has experience in using fortification

technology it will be a simpletransitionto fortifytheDaffodil icorn meal during its production

C Monitoring

The importance of establishing the efficacy of an iron fortification program

cannot-be over emphasized It is seldom possible to measure the impact of a

fortification program once itlis implemented and this is particularlytrue

with respect to ironfortification Incontrast to fortification with nutrishy

ents such as niacin thiamine or riboflavin where the objective is to preshy

vent -the occurrenceof isolated deficiencies it is feasible to alterbody

iron stores of-an entire population through dietary manipulation

The customary approach to monitoring efficacy is to conduct a pilot study

but there are several drawbacks to this Duringa preliminary trial the

supply of a fortified food s usually ensured whereas -this is not necessarily

the case when implemented ona national scale Another importantlimition

of a preliminary iron trial is that because of the inhibitingeffect of the

diet on iron absorption changes in iron status in a populationproduced by

ironfortification occur ery slowly often only after several years IotPil

studies therefore delay the implementation of a fortification program and

are very costly because of the long duration ofthe trial

ne Way to circumvent the high cost of pilot s s to impementiron

fortification in a country in stages In the case of fortified cornmeal for

example one could supply the product to a certain geographic region

Because the major target of this program is 6-24 month old linfants baseline

iron status measurements would be performed immediately prior to introducing

the iron fortified cornmeal Approximately 300 infants 18-24 monthsof age

should be surveyed intwo widely separate geographic regions of the country

One regionwill be supplied with iron fortified cornmeal while the second

region will serve as a control Within each region 200-300 infants inthesp

cified age group will be selected randomly from bothrural andurban areas

Baseline laboratory measurements will include hematocri t(or hemoglobin)

free erythrocyte protoporphyrin and serum ferritin All of these microshy

method measurements can be performed on capillary blood samples After 14

months of fortification a second random sampling of infants inthe sameage

group (18-24 months)wil1 be6 performed inboththe control and the-fortifishy

cation regions Longitudinal changes in iron status resultingfromi factors

other than fortification of cornmeal such as more effective fortification of

wheat flour could be assessed by changes overtime inthe control region whereas the impact ofcornmeal fortificationcan be measured by serial

changes within the region receiving iron fortified products Finally by

including more specific-measurements Iof iron status rather than just

hemoglobin determinations the effect on iron balance rather than anemia can

be determined

Estimated cost for this preliminary monitoring activity for stage one ofia

fortification program isIncluded in the attached budget

D Quality Assurance

During stage one and throughout an iron fortification programiquality

assurance activities must be carried out to verify the iro cntent of the

fortified flours and corn meal Sampling and testing for iron content

should be carried out routinely at the mills during the production of the

products The in-plant quality testing should be the responsibility ofand

carried out by the companies since theyhave the laboratory facilities and

good technical personnel with which to do this

Samples of products should be drawn periodically from the market shelfby

designated government representatives and analyzed for iron content This

13

isneeded to verify-both the presence of added iron and inthe proper amount

These lsamples could be analyzed in the laboratories of theMinistries of

Health orAgriculture or inother suitable government facilities

This level of quality assurance activity isnecessary to ensure that there

ils a given level of iron intake each day based on expected consumption-A

successful intervention can be accomplished only when the iron ispresent

inthe food on a continuing basis inthe correct amount Anythingless than

this could lead to unsatisfactory results due to lack of proper control

rather than a failure of the interventiOniitself


A nutrition education or public service informationactivity should be

carried out inconjunction with stage one of a program for the iron fortishy

fication of corn meal It should include information about iron in

nutrition the need-for iron inthe bodythe benefits to be derivedfrom

moreiron inthe diet and the consequences of too little iron In addition

it should explain that iron isbeing added to the corn meal available

in certain parishes stressing the fact thatit is iron that is being added

and that it isonly for nutritional improvement purposes The message should

be directed only to the test region that would receive iron fortified corn

meal during stage one if-possible and not tothe whole-nation initially

When the program goes national the same type of activities would be carried

out nationwide regarding cornmeal

The mechanism mightbe special announcements over radio stations flyers or

posters at the point of sale in the markets andA in the clinics and health

centers and by word-of-mouth inthe MCH centers etc Most of this informashy

tion dissemination should be able to b carried out free-of-charge d

14

public-service a healthnutrition measure etc There isno estimate at this time what itwould cost to print a sufficient number of posters etc

In regard to the addition of iron along withB-vitamins to counter-floura

part of the wheat flour- component of aprogram typical announcements or

advertisements by Jamaica- Flur Mill Ltdor other appropriate entity shoulc

be used to inform the people of the increased nutritional value of countershy

flour with emphasis o1n the added iron


The possible adverse effect ofadding largeamounts-of iron to thediiet incershy

tai segments of a population has been discussedI from time to time and deserves

comment Inreviewing studies inwhich possible adverse affects ofiron have

been reported it is important to define the route ofiron administration When

large doses of Imferon (iron dextran) were given by deep subcutaneous injection

to newborn infants an increased frequency of fatal septicemia was noted butit

was not clearwhether this was due to iron or dueto the intramuscular injecshy

tion There is some published evidence that the frequency of malaria may

increase when full doses of therapeutic oral iron are administered to a suscepshy

tible population

On the other hand it- must be stressed that noiadverse effects have iyet been

demonstrated when conventiona levels of iron fortification have been Imple-

mented inapopulation Homozygotes for the iron loading gene ie idiopathic

hemochromatosis have been demonstrated to occur in 1300-500 American whites

but this genetic disorder hasnever been clearly identified ina black indivishy

dual Countries such as Swedenare continuing to fortify the diet at a level

thatprovides approximattely 40 of-dietaryiron intake Without demonstrable

adverse effecs Therefore there seems to be little basis for concerns for a

15

fortification program that will double the intake of dietary iron even in iron

repleteindividuals Nevertheless because of the complete lack of information

on themaximal consumptionof corn meal by older childrenand adults it is

desirable to establish consumption patterns of thi sfood vehiclethroughout the

population

IV ADDITIONAL INFORMATiON INEEDED

Additional information of various types needs to be collected justprior to or

duringstage one of an ironfortification program The information will be used

in the planning and operation of stage one aswell as provide the basis to make

any adjustments that appear neededin the final planning for nationwideimpleshy

mentation of lthe program Descriptions of the kind of information needed and

how to obtain- it follow


Data is needed on the quantity and distribution of consumption of corn meal

among the family members To obain this information a survey of mothers

should be conducted in MCH centers andor public health centers across the

country Thesurvey should include thecompletion of a questionnaire

regarding all aspects of the use of corn meal in the home Interviewers

would contact the mothers upon their visit to the centers and obtain the

first-hand information It is estimated that interviewers working half-days

for a month at 14 centers across the country could complete approximately

2700 interviews This should represent an adequate sample size and crossshy

section for accurate information on household use of cornmeal

The questionnaire could contain a few questions reg rdingpurchase and us

of counter-flour by the household These questions wouldprovide inforshy

mation on the length of time counter-flour is held inthe home -This could

be important tothe expectedshelf life of counter-flOur containingferrous

sulfate

16

Mini stryof Health response to the suggestion of using the centers as data

collection points wa spositive and was expressed in cooperatinginterest

in the planningof sucha survey Personnel to conduct the survey would

have to be independent of the MOH however A cost estimate for asurvey 15

shown in the attached budget


Information is needed regarding the response of children tobullincreased daily

intake of iron from corn meal at iilthe levels used in stage one of anr

iron fortification program -To facilitate the collectionofsuch datait

is necessary to haveareas in which only iron fortified corn meal is

available and othersin which only non-fortified corn meal is available

Activities carried out to determine the iron nutriture status of children

would be part of the monitoring function for theprogram before it is exshy

panded to a nationwide Ibasis (See Section III CMonitoring)

The establishment of iron fortified and control areas for corn meal can be

-accomplished throughconrolled distributionof the proper corn meal to the

respective areas Representatives of Seprod Ltd indicated that they are

willing to cooperate in such an operation in order to establish the necessary

areas They suggested-thatthe two or three parishes in the eastern end

of the country ie Portland St Thomas etc be used as the test

(fortified) area because they lend themselves to far better1control of the

distributionof the corn meal due to-the marketing and distribution pattern

of the company in that area Details of such an activity for controllingshy

the distri bution of iron fortified corn-meal fromplant to-store shelf need

to beworked out with Seprod personnel This activity will helpin the

collection of baseline iron status measurements as well as the data relating

to the response to increased iron intake

17

C Quality of Corn Meal iwith Added Iron

Because there are differences in production use and conditions encountered

for any given food in different countries information should be obtained

on theretention of quality of corn meal which has had ferroussulfate

added to i t Corn meal should be fortified with iron to the suggestedlevel

of 40 mgb and placed in holding tests which duplicate the conditions the

corn meal willmeetduringdistribution and use The corn meal shouldbe

evaluatedforcolor odor and taste after-holding under typical Jamaican

conditions for periods1of time representingkexpected sheelf life Ietimeli

from prod uctiobn unt il use

Typical production corn meal should be used along with a source of ferrous

sulfate that would be used in a fortification program


iThe-same philosophy and-need for information applies to the addition of

ferrous sulfate to counter-flour as for the addition of such Iron to corn

meal The testing should include the addition of 20mg of ferrous sulfate

(plus B-vitamins) per pound of flour followed by holding tests under expected

time and conditions Then organoleptic evaluation for odo color etc

should be carriedout on the stored product

No information was available about how long counter-flour i on the shelf

and inthe home before it is used Comments received during discussions

about counter-flour indicated that the flour ison the shelf only a short

time and on-occasion isnot available There was no indication of-how long

it was the homein before-use

21

18

Some measure of the storage time in the home could be obtained by having

a question or two on the questionnaire to-be used in the corn meal conshy

sumption survey

E Addition of Ferrous Sulfate to Bakery Flour

Theshelf life of bakery flour isreported to be3-4 days fromproduction

touse The presence of-ferrous sulfate in the flour should not affect the

qual ity of theflour Any concern wouldresidewith the special permix

itself which is added to the flourto provide the nutrients and otheringre

dients As indicated earlier this premix is a blend of more than the usual

naterialsused in an enrichment premix and the length oftimefrom its proshy

luction to use may be longer than usual for premixes

should estsbe carried out to check the stability of the special premix

ontaining ferrous sulfate subjected to conditions and time that will be

net between its production and its use inthe mill

99V


1 A national cereal fortification program should be instituted which has as

its goal the iron fortification of all corn meal and wheatflour consumed

in Jamaica The program could be the result of a project which provides

information on (1)theadequacy of the production distribution and qualit

assurance components of a fortification program (2)thesuitability of

ferrous sulfate as the iron source to fortify the foods and (3)theimproveshy

ment-in iron status ofrecipients of fortified corn meal as an indication

ofthe adequacy of the level of added ironshy

2 The source of iron used in the fortification of cereal foods should be a

highly available form such as ferrous sulfate The suggested levels are

20 mg per pound for wheat flour and 40 mg per pound for corn meal This

level for wheat flour is higher than that presently used in Jamaica and

equals the new level in some countries with iron fortification programs

The level for corn meal is higher than for wheat flour because of the

universal requirement for additionaldietary iron during the first two

years of life and the fact that corn mealis used almost exclusively as a

weaning food throughout Jamaica This level of iron will meetor exceed

the Jamaican RDA for iron (7mgday) in6-24 month old children based on

the present consumpt ion information

3 m 5urvey snuiuuecarrea ouLTo aeterminetne als rioution and amountof

consumption of corn meal in the family This should be done as soon as

possible andneed not be a part of-a project though itmi ght be The inshy

formation it wouldprovide is needed-for other considerations in child

health and nutriiion ifnot directly used iniron fortificationprograms

20

The information would be-valuable indetermining the daily intake of iron

by infants children andadults that could result from the consumption of

fortified corn meal Itwouldindicate whether the recommended levels of

iron additionwould be sufficientfor a child yet not lead to an excess

intake of iron by adul ts that could beharmful

4 A project should be carried out whichwould include the initial addition of

iron toall corn meal and wheat flour made in-country It could be

implemented inthree stages Step onewould include (a)limited-introduction

of iron fortifiedcornmeal and (b)initial in-country production of countershy

flour fortified with iron and B-vitamins Stagetwo would be the start of

use of ferrous sulfate as the iron source inbread flour produced intheshy

country and Stage three-would be theexpansion of the availability of iron fortified cornmeal t thewhole countrY pl any changes iniron level

iron source or otherfactors-found necessary to help assure the success of

a national cereal fortification program

5 Stage one should be started immediately after completion of the cornmeal

consumption survey or as soon as conditions allowafter that It should-

involve controlled distribution resulting inoIly iron fortified corn meal

beingavailable in a prescribed area This would be accompaniedby a monishy

toring activity to measure the response to added iron through this intervenshy

ion Baseline and 18month follow-up studies of iron status should be pershy

formed on randomly selected two year old infants both inthe fortified and

non-fortified areas Also it should include the production and distribution

of counter-flour fortified with ferrous sulfate and B-vitamins Samples

should be tested-routinely for iron content and consumer acceptability

These activitieswill provide information n any- needed changes in iron

level on-the acceptability of the-iron source and on the adequacy of the

production and distribution of fortified corn meal and counter-flour

21

6 Afnutrition education component should be included as part of a project Activities should-be-carried out before and during stage one in the area

receiving fortified corn meal It should informthe recipients of fortishy

fied corn meal about the nutritionalvalue of the added ironand the beneshy

fitsto be derived-from it

A general information campaign should be carried-out nationwide telling of

the improvednutritional value of counter-flour inregardsto iron dontent

whenitis introduced into the market

Similar informationshould be made avai lable in stage two about the changoe in

iron source in the bakery flour to one in a more useable form by the

consumer

In stagethree the information aboutfortified corn meal shuld e dis

nated nationwide accompanied by thecontinuing actiVities regarding countershy

flour and bakery flour

APPENDICES

APPENDIX A

Estimated Budget -StageOne -Iron Fortificaion Program

Activity Cost

Corn Meal Consumption Survey us 6000

Baseline Study and Monitor of IronStatus 69000

Technical Assistance for Preparation

of-Project Paper 1800

Iron for 18 monthCornMealFortification (Seprod)

Iron for Counter-Flour 0amaica Flour MillLtd

Total

$76800

APPENDIX B

People-Contacted

Many of the people mostl associated with the problem of anemia inJamaica were

presentat the-Workshop on irondeficiency anemia held Monday June 25 1984

(See attached meeting iagenda-) Alsoin attendance were representatives-of the

flour milling and corn meal production companies who described the industries

concern and willingness-to cooperate inefforts to redu6e anemia

Inaddition tothe discussionsduring the workshop indepth discussions were

held with the following people on matters related to a program to combat anemia

Jamaica Flour Mills Ltd

Mr Peter Pickett Director of Operations

Seprod Ltd

Mr A Summons Market Manager

Ministry of Health

Dr Bowenwright

Mrs K Rainford

Caribbean Food and Nutrition Institute

Dr Patterson Director

Dr B Simmons Nutritionist

Ms Sadie Campbell Nutritionist

Tropical Medicine Research Unit

Dr- Alan Jackson

APPENDIX C

DRAFT AGENDA

IRONANEMIA SCREENiNG TREATMENT AND rPREVENTION

-900 910 WelcomingRemarks - Dr W Patterson Director CFNI

910 - 925 Anemia Studies in Jamaica - Dr BSimons CFNI

925 950 Screening TreatmentampPrevention Programs -Dr DAshle PMOMCH MOH

-950 -1005 Recent Research Findings Dr Alan Jackson-TMRU

1005 -1015 Dietary Iron Sources in Jamaica Ms Sadie Campbell Nutritionist CFNI

1005 -1030 Discussion

1030- 1045 Clinical Analysis of Anemia - Dr Goldman Department of Hematology UWI

1045-1100 International Anemia Programs - Dr James Cook Director Department of Hematology Kansas University Medical Center

1100 -1115 Anemia Programs in Jamaica - Dr Gibbs Director Department of Hematology UWI Medical Centershy

-111115 30 Discussion

1130 --1140 Refreshment Break

1140-1150 Present Fortification of Wheat Products in Jamaica - Mr Vassel Chief Chemist Director Pilot Bakery Jamaica Flour Mills

1150 1200 Present Fortification of Cornmeal inJamaica Mr B Thompson Manufacturing Manager Seprod Ltd

1200- 1215 Present Cereal Fortification in the United States - Dr Fred Barrett Fortification Specialist United States Department of Agriculture

1215 - 1230 Closing Discussions

Any and all of these activities indicate agood start toward a valuable nroiet and subsequently a successful fortification program

Iwould greatly welcome hearing from you periodically ontheprogresstoward aniron fortification program

Fred F Barrett PhD Food Technologist Nutrition amp Agribusiness Group

cc N Luykx STN SKahn STN

Enclosure AS


IN JAMAICA

REPORT


and







CONTENTS

I BACKGROUND-



A Wheat Flour

B Corn Meal

C- Monitoring

D Quality Assurance










APPENDICES

A Estimated Budget

B People Contacted

C Workshop Outline

I BACKGROUND






in Jamaica







were developed~are












to it

2

























9

3



























2)

4
















daily diet








5



















































7



















per pound of flour




1

8










in other countries









B-vitamin s






9
























10






























C Monitoring






































be determined



D Quality Assurance










13



























14

















tible population









15





population























sulfate

16




























17

























21

18



sumption survey












99V


























20




























21










consumer




APPENDICES

APPENDIX A


Activity Cost







Total

$76800

APPENDIX B

People-Contacted










Seprod Ltd


Ministry of Health

Dr Bowenwright

Mrs K Rainford






Dr- Alan Jackson

APPENDIX C

DRAFT AGENDA


















IN JAMAICA

REPORT


and







CONTENTS

I BACKGROUND-



A Wheat Flour

B Corn Meal

C- Monitoring

D Quality Assurance










APPENDICES

A Estimated Budget

B People Contacted

C Workshop Outline

I BACKGROUND






in Jamaica







were developed~are












to it

2

























9

3



























2)

4
















daily diet








5



















































7



















per pound of flour




1

8










in other countries









B-vitamin s






9
























10






























C Monitoring






































be determined



D Quality Assurance










13



























14

















tible population









15





population























sulfate

16




























17

























21

18



sumption survey












99V


























20




























21










consumer




APPENDICES

APPENDIX A


Activity Cost







Total

$76800

APPENDIX B

People-Contacted










Seprod Ltd


Ministry of Health

Dr Bowenwright

Mrs K Rainford






Dr- Alan Jackson

APPENDIX C

DRAFT AGENDA

















CONTENTS

I BACKGROUND-



A Wheat Flour

B Corn Meal

C- Monitoring

D Quality Assurance










APPENDICES

A Estimated Budget

B People Contacted

C Workshop Outline

I BACKGROUND






in Jamaica







were developed~are












to it

2

























9

3



























2)

4
















daily diet








5



















































7



















per pound of flour




1

8










in other countries









B-vitamin s






9
























10






























C Monitoring






































be determined



D Quality Assurance










13



























14

















tible population









15





population























sulfate

16




























17

























21

18



sumption survey












99V


























20




























21










consumer




APPENDICES

APPENDIX A


Activity Cost







Total

$76800

APPENDIX B

People-Contacted










Seprod Ltd


Ministry of Health

Dr Bowenwright

Mrs K Rainford






Dr- Alan Jackson

APPENDIX C

DRAFT AGENDA

















I BACKGROUND






in Jamaica







were developed~are












to it

2

























9

3



























2)

4
















daily diet








5



















































7



















per pound of flour




1

8










in other countries









B-vitamin s






9
























10






























C Monitoring






































be determined



D Quality Assurance










13



























14

















tible population









15





population























sulfate

16




























17

























21

18



sumption survey












99V


























20




























21










consumer




APPENDICES

APPENDIX A


Activity Cost







Total

$76800

APPENDIX B

People-Contacted










Seprod Ltd


Ministry of Health

Dr Bowenwright

Mrs K Rainford






Dr- Alan Jackson

APPENDIX C

DRAFT AGENDA

















2

























9

3



























2)

4
















daily diet








5



















































7



















per pound of flour




1

8










in other countries









B-vitamin s






9
























10






























C Monitoring






































be determined



D Quality Assurance










13



























14

















tible population









15





population























sulfate

16




























17

























21

18



sumption survey












99V


























20




























21










consumer




APPENDICES

APPENDIX A


Activity Cost







Total

$76800

APPENDIX B

People-Contacted










Seprod Ltd


Ministry of Health

Dr Bowenwright

Mrs K Rainford






Dr- Alan Jackson

APPENDIX C

DRAFT AGENDA

















3



























2)

4
















daily diet








5



















































7



















per pound of flour




1

8










in other countries









B-vitamin s






9
























10






























C Monitoring






































be determined



D Quality Assurance










13



























14

















tible population









15





population























sulfate

16




























17

























21

18



sumption survey












99V


























20




























21










consumer




APPENDICES

APPENDIX A


Activity Cost







Total

$76800

APPENDIX B

People-Contacted










Seprod Ltd


Ministry of Health

Dr Bowenwright

Mrs K Rainford






Dr- Alan Jackson

APPENDIX C

DRAFT AGENDA

















4
















daily diet








5



















































7



















per pound of flour




1

8










in other countries









B-vitamin s






9
























10






























C Monitoring






































be determined



D Quality Assurance










13



























14

















tible population









15





population























sulfate

16




























17

























21

18



sumption survey












99V


























20




























21










consumer




APPENDICES

APPENDIX A


Activity Cost







Total

$76800

APPENDIX B

People-Contacted










Seprod Ltd


Ministry of Health

Dr Bowenwright

Mrs K Rainford






Dr- Alan Jackson

APPENDIX C

DRAFT AGENDA

















5



















































7



















per pound of flour




1

8










in other countries









B-vitamin s






9
























10






























C Monitoring






































be determined



D Quality Assurance










13



























14

















tible population









15





population























sulfate

16




























17

























21

18



sumption survey












99V


























20




























21










consumer




APPENDICES

APPENDIX A


Activity Cost







Total

$76800

APPENDIX B

People-Contacted










Seprod Ltd


Ministry of Health

Dr Bowenwright

Mrs K Rainford






Dr- Alan Jackson

APPENDIX C

DRAFT AGENDA










































7



















per pound of flour




1

8










in other countries









B-vitamin s






9
























10






























C Monitoring






































be determined



D Quality Assurance










13



























14

















tible population









15





population























sulfate

16




























17

























21

18



sumption survey












99V


























20




























21










consumer




APPENDICES

APPENDIX A


Activity Cost







Total

$76800

APPENDIX B

People-Contacted










Seprod Ltd


Ministry of Health

Dr Bowenwright

Mrs K Rainford






Dr- Alan Jackson

APPENDIX C

DRAFT AGENDA

















7



















per pound of flour




1

8










in other countries









B-vitamin s






9
























10






























C Monitoring






































be determined



D Quality Assurance










13



























14

















tible population









15





population























sulfate

16




























17

























21

18



sumption survey












99V


























20




























21










consumer




APPENDICES

APPENDIX A


Activity Cost







Total

$76800

APPENDIX B

People-Contacted










Seprod Ltd


Ministry of Health

Dr Bowenwright

Mrs K Rainford






Dr- Alan Jackson

APPENDIX C

DRAFT AGENDA

















8










in other countries









B-vitamin s






9
























10






























C Monitoring






































be determined



D Quality Assurance










13



























14

















tible population









15





population























sulfate

16




























17

























21

18



sumption survey












99V


























20




























21










consumer




APPENDICES

APPENDIX A


Activity Cost







Total

$76800

APPENDIX B

People-Contacted










Seprod Ltd


Ministry of Health

Dr Bowenwright

Mrs K Rainford






Dr- Alan Jackson

APPENDIX C

DRAFT AGENDA

















9
























10






























C Monitoring






































be determined



D Quality Assurance










13



























14

















tible population









15





population























sulfate

16




























17

























21

18



sumption survey












99V


























20




























21










consumer




APPENDICES

APPENDIX A


Activity Cost







Total

$76800

APPENDIX B

People-Contacted










Seprod Ltd


Ministry of Health

Dr Bowenwright

Mrs K Rainford






Dr- Alan Jackson

APPENDIX C

DRAFT AGENDA

















10






























C Monitoring






































be determined



D Quality Assurance










13



























14

















tible population









15





population























sulfate

16




























17

























21

18



sumption survey












99V


























20




























21










consumer




APPENDICES

APPENDIX A


Activity Cost







Total

$76800

APPENDIX B

People-Contacted










Seprod Ltd


Ministry of Health

Dr Bowenwright

Mrs K Rainford






Dr- Alan Jackson

APPENDIX C

DRAFT AGENDA



















C Monitoring






































be determined



D Quality Assurance










13



























14

















tible population









15





population























sulfate

16




























17

























21

18



sumption survey












99V


























20




























21










consumer




APPENDICES

APPENDIX A


Activity Cost







Total

$76800

APPENDIX B

People-Contacted










Seprod Ltd


Ministry of Health

Dr Bowenwright

Mrs K Rainford






Dr- Alan Jackson

APPENDIX C

DRAFT AGENDA































be determined



D Quality Assurance










13



























14

















tible population









15





population























sulfate

16




























17

























21

18



sumption survey












99V


























20




























21










consumer




APPENDICES

APPENDIX A


Activity Cost







Total

$76800

APPENDIX B

People-Contacted










Seprod Ltd


Ministry of Health

Dr Bowenwright

Mrs K Rainford






Dr- Alan Jackson

APPENDIX C

DRAFT AGENDA

















13



























14

















tible population









15





population























sulfate

16




























17

























21

18



sumption survey












99V


























20




























21










consumer




APPENDICES

APPENDIX A


Activity Cost







Total

$76800

APPENDIX B

People-Contacted










Seprod Ltd


Ministry of Health

Dr Bowenwright

Mrs K Rainford






Dr- Alan Jackson

APPENDIX C

DRAFT AGENDA

















14

















tible population









15





population























sulfate

16




























17

























21

18



sumption survey












99V


























20




























21










consumer




APPENDICES

APPENDIX A


Activity Cost







Total

$76800

APPENDIX B

People-Contacted










Seprod Ltd


Ministry of Health

Dr Bowenwright

Mrs K Rainford






Dr- Alan Jackson

APPENDIX C

DRAFT AGENDA

















15





population























sulfate

16




























17

























21

18



sumption survey












99V


























20




























21










consumer




APPENDICES

APPENDIX A


Activity Cost







Total

$76800

APPENDIX B

People-Contacted










Seprod Ltd


Ministry of Health

Dr Bowenwright

Mrs K Rainford






Dr- Alan Jackson

APPENDIX C

DRAFT AGENDA

















16




























17

























21

18



sumption survey












99V


























20




























21










consumer




APPENDICES

APPENDIX A


Activity Cost







Total

$76800

APPENDIX B

People-Contacted










Seprod Ltd


Ministry of Health

Dr Bowenwright

Mrs K Rainford






Dr- Alan Jackson

APPENDIX C

DRAFT AGENDA

















17

























21

18



sumption survey












99V


























20




























21










consumer




APPENDICES

APPENDIX A


Activity Cost







Total

$76800

APPENDIX B

People-Contacted










Seprod Ltd


Ministry of Health

Dr Bowenwright

Mrs K Rainford






Dr- Alan Jackson

APPENDIX C

DRAFT AGENDA

















18



sumption survey












99V


























20




























21










consumer




APPENDICES

APPENDIX A


Activity Cost







Total

$76800

APPENDIX B

People-Contacted










Seprod Ltd


Ministry of Health

Dr Bowenwright

Mrs K Rainford






Dr- Alan Jackson

APPENDIX C

DRAFT AGENDA










































20




























21










consumer




APPENDICES

APPENDIX A


Activity Cost







Total

$76800

APPENDIX B

People-Contacted










Seprod Ltd


Ministry of Health

Dr Bowenwright

Mrs K Rainford






Dr- Alan Jackson

APPENDIX C

DRAFT AGENDA

















20




























21










consumer




APPENDICES

APPENDIX A


Activity Cost







Total

$76800

APPENDIX B

People-Contacted










Seprod Ltd


Ministry of Health

Dr Bowenwright

Mrs K Rainford






Dr- Alan Jackson

APPENDIX C

DRAFT AGENDA

















21










consumer




APPENDICES

APPENDIX A


Activity Cost







Total

$76800

APPENDIX B

People-Contacted










Seprod Ltd


Ministry of Health

Dr Bowenwright

Mrs K Rainford






Dr- Alan Jackson

APPENDIX C

DRAFT AGENDA

















APPENDICES

APPENDIX A


Activity Cost







Total

$76800

APPENDIX B

People-Contacted










Seprod Ltd


Ministry of Health

Dr Bowenwright

Mrs K Rainford






Dr- Alan Jackson

APPENDIX C

DRAFT AGENDA

















APPENDIX A


Activity Cost







Total

$76800

APPENDIX B

People-Contacted










Seprod Ltd


Ministry of Health

Dr Bowenwright

Mrs K Rainford






Dr- Alan Jackson

APPENDIX C

DRAFT AGENDA

















APPENDIX B

People-Contacted










Seprod Ltd


Ministry of Health

Dr Bowenwright

Mrs K Rainford






Dr- Alan Jackson

APPENDIX C

DRAFT AGENDA

















APPENDIX C

DRAFT AGENDA

















Documents

August 1984 - United States Agency for International ...pdf.usaid.gov/pdf_docs/pdwae276.pdfmeal with ferrous sulfate added to it. I . have talked with the US supplier of the premix