wheat flour fortification program in bangladesh

The USAID Micronutrient Program

Wheat Flour FortificationProgram in Bangladesh

Final ReportOctober 2003

Wheat Flour FortificationProgram in Bangladesh

Final Report

October 2003

This publication was made possible through support provided by the Office of Health, Infectious Diseases andNutrition, of the Bureau for Global Health, U.S. Agency for International Development (USAID).

MOST is managed by the International Science and Technology Institute, Inc. (ISTI) under the terms of CooperativeAgreement No. HRN-A-00-98-0047-00. Partners are the Academy for Educational Development (AED), Helen KellerInternational (HKI), the International Food Policy Research Institute (IFPRI), and Johns Hopkins University (JHU).Resource institutions are CARE, the International Executive Service Corps (IESC), Population Services International(PSI), Program for Appropriate Technology in Health (PATH), and Save the Children.

The opinions expressed in this document are those of the author(s) and do not necessarily reflect the views of theU.S. Agency for International Development.

The MOST Project1820 N. Fort Myer Drive, Suite 600Arlington, VA 22209 USATelephone: (703) 807-0236 Fax: (703) 807-0278Web site: http://www.mostproject.orgE-mail: [email protected]

iii

TABLE OF CONTENTS

LIST OF ACRONYMS................................................................................................................v

EXECUTIVE SUMMARY.......................................................................................................... vii

Background......................................................................................................................viiObjectives of the Final Report ...........................................................................................viiProgram Achievements .....................................................................................................viiProgram Findings ............................................................................................................viiiCritical Dimensions of a Sustainable Wheat Flour Fortification Program............................... ixNext Steps .........................................................................................................................x

CHAPTER 1: INTRODUCTION....................................................................................................1

1.1 Background and Objectives of the Trial Program..........................................................11.2 Objectives of the Final Report .....................................................................................2

CHAPTER 2: PROGRAM ACHIEVEMENTS...................................................................................5

2.1 Organoleptic Test .......................................................................................................52.2 Acceptability and Utilization Survey Results ................................................................52.3 Education and Promotion ............................................................................................62.4 Cost Analysis .............................................................................................................62.5 Efficacy Study............................................................................................................72.6 Quality Assurance and Quality Control........................................................................8

CHAPTER 3: THE WHEAT FLOUR MARKET AND THE STRUCTURE OF THE MILLING INDUSTRY......9

3.1 Wheat and Wheat Flour in Bangladesh.........................................................................93.2 Milling and Milling Technology ................................................................................10

3.2.1 Mills ...........................................................................................................103.2.2 Milling Technology ......................................................................................10

3.3 The Flour Market......................................................................................................113.3.1 General Characteristics .................................................................................113.3.2 Market Size ..................................................................................................123.3.3 Prices ..........................................................................................................123.3.4 Advertising...................................................................................................13

CHAPTER 4: TOWARD A SUSTAINABLE WHEAT FLOUR FORTIFICATION PROGRAM .................... 15

4.1 Sustainability of the Current Program ........................................................................154.2 Selecting a Suitable Manufacturing Method................................................................154.3 Choosing between a Mandatory and a Voluntary Program...........................................164.4 Quality Control, Quality Assurance and Monitoring....................................................164.5 Packaging and Labeling ............................................................................................164.6 Partnership with the Private Sector ............................................................................174.7 Consumer Participation .............................................................................................174.8 Regulatory Issues .....................................................................................................18

iv

CHAPTER 5. BEYOND THE PILOT ACTIVITY: PROMOTING A NATIONWIDE WHEAT FLOURFORTIFICATION PROGRAM .................................................................................................... 19

5.1 Progress to Date .......................................................................................................195.2 Next Steps ...............................................................................................................19

5.2.1 Developing Manufacturing Standards.............................................................205.2.2 Establishing and Maintaining Fortification Capability.....................................205.2.3 Developing Adequate Quality Control and Quality Assurance.........................215.2.4 Enforcement.................................................................................................215.2.5 Program Monitoring and Evaluation...............................................................215.2.6 Developing a Public-Education Campaign......................................................21

APPENDICES

APPENDIX A: LIST OF STUDIES, TECHNICAL REPORTS AND TRIP REPORTS PREPARED UNDER THEPILOT PROGRAM

APPENDIX B: RANDOMIZED, DOUBLE-BLIND CONTROLLED TRIAL OF WHEAT FLOUR FORTIFIEDWITH VITAMIN A AND IRON IN IMPROVING VITAMIN A AND IRON STATUS INHEALTHY, SCHOOL AGED CHILDREN IN RURAL BANGLADESH

APPENDIX C: ACCEPTABILITY AND UTILIZATION OF FORTIFIED ATTA DISTRIBUTED UNDER THEPILOT PROJECT FOR ATTA FORTIFICATION - PART I

APPENDIX D: ACCEPTABILITY AND UTILIZATION OF FORTIFIED ATTA DISTRIBUTED UNDER THEPILOT PROJECT FOR ATTA FORTIFICATION - PART II

v

LIST OF ACRONYMS

BSTI Bangladesh Standards and Testing InstituteDGF Directorate General of Food, under MOFGOB Government of BangladeshFFE Food for EducationICDDR, B International Center for Diarrheal Disease Research in BangladeshINFS Institute of Nutrition and Food SciencePFDS Public Food Distribution SystemMT Metric TonMOF Ministry of FoodMWCA Ministry of Women and Children AffairsNGO Non-Government OrganizationPFDS Public Food Distribution SystemQA Quality AssuranceQC Quality ControlTk Taka (Bangladesh currency)VGD Vulnerable Group Development Program, under MWCAUSAID United States Agency for International DevelopmentWFP World Food Programme of the United Nations

Executive Summary

vii

EXECUTIVE SUMMARY

BACKGROUND

The wheat flour fortification program in Bangladesh is a limited-term project to determine thefeasibility of increasing micronutrient intake among children by fortifying wheat flour withvitamin A, iron, zinc, B1, B2, niacin and folic acid.

Vitamin A and iron deficiency has led to high rates of night blindness, anemia, reduced immuneresponse and other health problems in Bangladesh, particularly among children. In 1995, theGovernment of Bangladesh (GOB) implemented a universal vitamin A capsule distributionprogram that achieved high coverage for children 6 months to 5 years of age. The program wassuccessful in decreasing the incidence of night blindness and other health problems associatedwith vitamin A deficiency. However, significant constraints remain for two major reasons.First, universal distribution does not reach all individuals who would benefit from vitamin Acapsules, including older children, and pregnant and lactating women. Second, not allmicronutrients can be supplied through capsule distribution.

In August 1999, USAID/Dhaka initiated a trial program to examine the feasibility of reducingmicronutrient deficiency through food fortification. The program was designed andimplemented by MOST, the USAID Micronutrient Program. Of the staple commoditiesconsidered for fortification, wheat flour was selected.

OBJECTIVES OF THE FINAL REPORT

The three major objectives of this report are (1) to highlight the achievements of the trial pilotproject; (2) to outline the critical elements of a sustainable wheat flour fortification program on anational scale; and (3) to recommend a package of key technical assistance interventions thatwould be required to support the transition from the ongoing activity to a nationwide program.

PROGRAM ACHIEVEMENTS

Since November 2000, USAID/Bangladesh designed and implemented a trial wheat flourfortification activity under the Vulnerable Group Development (VGD) Program. The WorldFood Programme (WFP) provided support to this effort. The fortified wheat flour was distributedby NGOs to VGD families. About 10,000 families participated in the program. In lieu of theusual monthly ration of 30kg of whole-grain wheat, recipient families were provided 25kg offortified chukki-mill atta (small stone-mill wheat flour).

Program activities were designed to generate important information on the feasibility of wheatflour fortification on a larger scale. To achieve this objective, several studies were conducted:

• An organoleptic study (analysis of the sensorial characteristics of a food - its taste, odor,color) to evaluate the organoleptic qualities of the fortified wheat flour and its products.

• An efficacy study to assess the health impact of the fortified wheat flour on the recipientpopulation.

• A utilization and acceptability study to ascertain beneficiaries’ use of the wheat flour.

Wheat Flour Fortification Program in Bangladesh

viii

• A cost analysis and sustainability study to assess cost factors and sustainability requirementsfor a nationwide program.

A quality assurance and quality control manual for fortification was prepared. A promotionaland educational campaign to inform recipients of the health benefits of the fortified wheat flourwas undertaken. The promotion and education activity generated an introductory video, postersand flyers, and included a training program for NGO staff who participated in the distribution ofthe fortified flour.

PROGRAM FINDINGS

Consumer Tastes and Preferences

The reactions of a panel of participants to chapati (flat bread) made from either fortified or non-fortified wheat flour provided information regarding consumer tastes and preferences. The panelshowed a strong preference for the chapati prepared from fortified atta (whole wheat flour) withhot water in all aspects investigated including taste, texture and appearance.

A major conclusion of the organoleptic study is that the chapati made from fortified atta usinghot water has a number of qualities with high acceptability to the panelists. Preparation with hotwater improved the texture of the chapatti. The fortified chapati was also preferred over thenon-fortified chapati due to the slightly salty taste imparted by the minerals contained in thefortified product.

Acceptance and Utilization of Fortified Wheat Flour

A survey based on about 1,000 households in 100 different villages provided information aboutconsumer willingness to use the fortified wheat flour. Over 90 percent of the sample surveyedconsumed 90 to 100 percent of the wheat flour distributed. The main reasons for consuminglesser amounts of the flour ration among certain recipients are losses from sifting the coarse flourand selling part of the allotment to meet other family needs. Loss from sifting is thought toderive, in part, from the fact that the wheat flour was left somewhat coarse to discourage resale.

It was found that over 95 percent of recipient households found the wheat flour ration moreconvenient than the prior ration of whole grain wheat. The shift to wheat flour averted the needfor milling, and the packaging by which the wheat flour was delivered made pilfering moredifficult.

A sample of rural families were given fortified roller-mill atta to test for its acceptability relativeto chakki-mill atta. Roller-mill atta was preferred for color, flavor and texture. The smoothtexture of roller-mill atta was particularly preferred over the coarseness and grainy texture ofchakki-mill atta.

Effectiveness of Fortified Wheat Flour for Addressing Iron and Vitamin A Deficiency

The program examined health and blood characteristics of a sample of 334 children in areaswhere the fortified roller-mill wheat flour was being distributed. Of the total sample, 191children were in households that received fortified wheat flour and 143 children comprised a

Executive Summary

ix

control group that had received non-fortified wheat flour. Data in the efficacy study weregathered on health and physical characteristics before the start of the project and again on thethird and sixth months of the trial activity.

A trend toward diminished vitamin A deficiency was found in the group that received fortifiedwheat flour, but not in the control group. Neither group showed a positive trend with regard toiron deficiency, suggesting that the program did not provide sufficient bioavailable iron to showa biological change.

Costs of Fortification

Fortification of wheat flour in Bangladesh will require very little modification of the usualmilling process and so will be a relatively simple and low-cost operation. The total cost offortification is estimated at Tk290 ($5USD) per MT. At Tk203 per MT, the premix is the singlelargest component (about 70 percent) of those costs. Since the cost of vitamin A is about 50percent of premix cost, not including vitamin A in the premix would lower its costs to aboutTk100 or $1.75 per metric ton. The total cost under this scenario would be about Tk190 orslightly higher than $3 per metric ton. It is, however, critical to include vitamin A despite itsrelative weight in fortification costs because of its importance in reducing micronutrientdeficiency and improving health.

It is important to note that fortification costs is estimated at 1.6 percent of the retail price forwhite flour (maida) in plastic bags suggesting that the additional cost of fortification does notappear prohibitive to consumers.

CRITICAL DIMENSIONS OF A SUSTAINABLE WHEAT FLOUR FORTIFICATION PROGRAM

Building on the Strength of a Highly Competitive Private Sector

The trial program has demonstrated that the current approach of producing fortified flour insmall chakki mills (small stone-mills) operated by NGOs is neither institutionally viable noreconomically sustainable under a nationwide program. First, if the fortification of wheat flour isto expand on a sustainable basis, it must be embedded in the current structure of the flourproduction and marketing system. Since the flour market in Bangladesh is driven by a vibrantand highly competitive private sector, any flour fortification program should build on this privatesector-based structure. Second, due to the small size of the chakki mills, their large number andtheir scattered distribution in remote locations in rural areas, they are difficult to regulate.

A Strategic Alliance between the Government and the Milling Industry

A successful national wheat flour fortification program is a strategic alliance between thegovernment and the milling industry. While the private sector is responsible for production anddistribution, government agencies define the parameters for quality control and implement theenforcement, monitoring and evaluation systems.


x

A Voluntary, Not a Mandatory Program

The structure of the milling industry in Bangladesh suggests that a mandatory flour fortificationprogram will not be realistic for two major reasons. First, the smaller mills, especially thoselocated in rural areas, typically will not have the capital resources needed to participate in thefortification program. Second, implementation of a quality assurance system and governmentinspection will not be possible when most participants consist of a large number of small millsscattered throughout the country.

NEXT STEPS

Available evidence suggests that while millers in Bangladesh are interested in fortification as ameans of adding value to their flour, a package of key interventions to support the transitionfrom the ongoing trial activity to a nationwide program will help create the conditions requiredfor the private sector to proceed. The information gathered should enable the millers to take theinitiative with the support of the Government of Bangladesh.

Developing manufacturing standards

Bangladesh has manufacturing standards for two types of flour, atta (whole wheat flour) andmaida (white flour). However, those standards do not specifically allow for micronutrientaddition. A second constraint is that the Pure Food Ordinance seems to prohibit the use ofadditives in flour. It will therefore be necessary to amend the Pure Food Ordinance and todevelop workable standards for fortified flour.

Establishing and maintaining fortification capability

Cost information developed under the trial program will help mill owners estimate what it willcost to embark on a fortification activity. It will also increase their confidence that fortificationcan be carried out at a cost that consumers can afford. However, the industry will still needguidance in determining which equipment to procure and how to modify its mills toaccommodate the new equipment. In addition, millers and supervisory personnel will needtraining in the operation and maintenance of the new equipment to ensure that the micronutrientsare being added in accordance with consumer safety requirements.

Much of the technical guidance and training needed by the private mills can be acquired frommanufacturers of the fortification equipment as well as from the suppliers of micronutrientpremixes. However, additional support will be needed from a local organization that can offerindependent technical advice and training on an as-needed basis. A multi-sectoral fortificationalliance would move the fortification goals forward; the work of the flour fortification studyhelped stimulate the formation of such an alliance.

Developing adequate quality control and quality assurance

Bangladeshi specialists will be needed to implement a sound quality control system for flourfortification. It is important that those specialists be trained in both ingredient application andquality control. Such training should include information on related topics such as flour additivesystems, additive-system maintenance and laboratory tests for micronutrients. Training in

Executive Summary

xi

quality control and quality assurance can be combined with training to establish and maintain afortification capability.

Enforcement

Setting up a regulatory monitoring system to validate producers’ claims and check micronutrientcontent will be a critical component of the wheat fortification program.

Program Monitoring and Evaluation

A major objective of program monitoring is to confirm that the fortified food is reachingconsumers. While regulatory monitoring shows whether the fortified product is delivered toconsumers in the appropriate amount and with the desired characteristics, household/individualmonitoring and evaluation will help policymakers document consumption and coverage, andassess biological impact.

Developing a public-education campaign

Under voluntary fortification, it is expected that the private sector will play a primary rolethrough advertising and other consumer marketing techniques to compete for consumerpreference. However, since fortification is a new concept to most consumers in Bangladesh, aninitial micronutrient promotion campaign by an outside organization to highlight the benefits offood fortification will be warranted.

Under the trial program, USAID and WFP have overcome the lack of knowledge by makingprovisions to educate participating VGD households about the benefits of fortified flour. A well-designed promotional effort will therefore be essential to the successful introduction of wheatflour fortification on a larger scale. Promotional activities would be directed at cognizant units ofgovernment, the milling sector and consumers.

In particular, consumers will need to be well informed about the benefits of the new productbefore they can be expected to purchase it. This is all the more important since, at the initialstage, consumers are unlikely to notice the difference between fortified and ordinary flour orhave any knowledge of the potential benefits that fortified flour may have.

Consumer acceptance will be greatly enhanced through an information dissemination programsponsored by government authorities and publicly supported by nationally renowned localscientists with established knowledge in nutrition.

Introduction

1

CHAPTER 1

INTRODUCTION

1.1 BACKGROUND AND OBJECTIVES OF THE TRIAL PROGRAM

Although food fortification has been going on successfully in industrialized countries fordecades, the transfer of the technologies employed to developing countries has, typically,required testing of those technologies and often their modification, before they can be applied ona large scale.

In 1999, MOST, The USAID Micronutrient Program, initiated efforts to establish a trial programin Bangladesh to verify the applicability of known fortification technologies given the nature ofthe local food industry and market. After examining a number of fortification options to increaseintake of vitamin A and iron among a targeted segment of the population, particularly womenand children in rural areas, the fortification of wheat flour was judged to have the greatestpotential.

In setting up the program, the following factors were taken into consideration:

• Introduce flour fortification with vitamins and minerals in a careful and systematic manner.• Standardize the quality of premix and the amount required per batch through recording,

testing and monitoring.• Ensure that facilities have the right mixers, feeders, and quality control equipment to meet

regulations governing food additives.• Ensure that sanitary conditions are maintained according to international management

practices.• Ensure that packaging, storage and distribution of products are done under conditions that

maintain effective levels of fortificants at the end-user level.

In March 2000, USAID/Dhaka agreed to allow MOST — the USAID Micronutrient Program —to proceed with the development of the trial activity in collaboration with the Food for EducationProgramme (FEP). In September of that year, the initial conditions for using FEP to distributefortified wheat flour were modified and an alternative distribution channel was identified. Indiscussions with the World Food Programme (WFP), it was agreed that the program could workin collaboration with the Vulnerable Group Development (VGD) Program. Among other things,the VGD program supplied low-income women with 30 kg of wheat per family, per month.

From November 2000 to March 2001, USAID and WFP collaborated in the design of the atta(whole wheat flour) fortification program. In April 2001 the structure of the program tookshape. The main features of the program were as follows:

• 18,000 VGD families (6 persons per family) would receive 25 kg of chakki mill (smallstone-mill) atta per month for 6 months. WFP would provide the wheat, chakki mills anddistribution system and MOST would supply fortificants, packaging materials andeducational materials on vitamin A and iron.


2

• 1,000 families would receive the same quantity of roller mill atta fortified and packaged fordistribution to VGD families using WFP wheat. Fortificants, packaging and educationalmaterials would be provided by USAID through MOST.

• A survey would be conducted by MOST to confirm beneficiaries’ acceptance of the fortifiedatta and investigate consumption patterns.

• A cost study would be conducted by MOST to investigate the cost of wheat flourfortification.

• MOST would also arrange for organoleptic testing of the fortified flour and an efficacy studythat would yield biochemical information on the health benefits of atta fortification.

In March 2002, the VGD program began distribution of fortified wheat flour in three districts,Gaibandha, Madaripur and Kushtia. Approximately 10,000 households were receiving 25 kg offortified wheat flour in lieu of the traditional VGD allotment of 30 kg of wheat. As the wheatflour obviated the need for milling and as the program provided the wheat flour in sealed packetsthat were less easy to pilfer, there was widespread approval among the beneficiaries for the shiftfrom wheat grain to wheat flour.

The wheat flour was milled and fortified at chakki mills located near the targeted villages.Imported from the United States, the premix was prepared to manufacture flour at the followingstandards:

Micronutrient Additive amounts (mg per kg of flour)

Thiamine (mononitrate) 6.4Riboflavin 4.0Niacin 53Folic acid 1.5Iron (hydrogen reduced) 66Zinc 33Vitamin A (palmitate 250 SD) 3

Prior to distribution of the fortified wheat flour, educational materials were developed and NGOstaff were taught how to use those materials to explain the benefits of fortification.

Among the beneficiary households, about 36 percent were headed by women. Over 80 percentof the beneficiary households had an income of less than Tk1,500 (about $26) per month, andover 55 percent of the member households had six or more members.

1.2 OBJECTIVES OF THE FINAL REPORT

The three major objectives of this report are (1) to highlight the achievements of the trialprogram; (2) to outline the critical elements of a sustainable wheat flour fortification program ona national scale; and (3) to define the next steps to support the transition from the on-goingactivity to a nationwide program.

Introduction

3

The following chapter describes the major results of several studies conducted under the trialprogram. Chapter 3 highlights the main characteristics of the market for wheat flour inBangladesh. Chapter 4 outlines sustainability considerations in the implementation of anationwide fortification effort. Information included in that chapter provides a basis forsuggesting needed interventions to ensure an effective transition from the on-going trial activityto a nationwide wheat fortification program.

Program Achievements

5

CHAPTER 2

PROGRAM ACHIEVEMENTS

2.1 ORGANOLEPTIC TEST

A study was prepared by the University of Dhaka Institute of Nutrition and Food Science toascertain the taste and quality impacts of fortification on chapati (flat bread) made from fortifiedatta (whole-wheat flour). This study monitored the reactions of a 10-person panel to fourdifferent types of chapati made from fortified and non-fortified wheat flour. The four chapatipreparation cases were as follows: fortified flour mixed with hot water, non-fortified flour mixedwith hot water, fortified flour with cold water, and non-fortified flour with cold water.

The table below provides the results of a hedonic preference for these four different cases.

Hedonic scale of overall satisfaction with different types of Chapati

Hedonic Scale Fortified Hot Control Hot Fortified Cold Control Cold

Highly liked 10 5 0 0

Slightly liked 0 5 0 0

Indifferent 0 0 5 0

Slightly disliked 0 0 5 3

Extremely disliked 0 0 0 7

Total 10 10 10 10

A major conclusion of the organoleptic study is that the chapati made from fortified atta usinghot water has a number of qualities with high acceptability to the panelists. Preparation with hotwater improved the texture of the chapati. The fortified chapati was also preferred over the non-fortified chapati due to the slightly salty taste imparted by the minerals contained in the fortifiedproduct.

2.2 ACCEPTABILITY AND UTILIZATION SURVEY RESULTS

An acceptability and utilization study was implemented in tandem with program fortification anddistribution activities. A sample of 988 households spanning 100 villages was enumerated. Thesurvey questionnaire addressed characteristics of the recipient families, their attitudes towardfortified wheat flour, and their awareness of the benefits of fortification.

The results showed that the level of consumption and utilization of fortified wheat flour washigh. Over 90 percent of the sample households consumed between 90 and 100 percent of their25 kg allotment of fortified wheat flour. Some families consumed lesser amounts. The lowerutilization rate was in some cases a result of recipients trying to sift the fortified flour, which wascoarser than standard, market wheat flour. In other cases, households sold a portion of theirallotment to meet other household needs.


6

In response to questions regarding the acceptability of the fortified flour, over 95 percent of therespondents reported that it was more convenient to receive their allotment in a milled form.About 90 percent of the sample thought that the fortified wheat flour tasted the same or betterthan market wheat flour. However, most respondents reported that the fortified wheat flour wascoarser than market wheat flour, a less-preferred characteristic.

In investigating the coarseness issue, the researchers discovered that project wheat flour wasdeliberately kept coarse by the mills to reduce its sale value and, thereby, the likelihood thatrecipient households would sell it. Participating mills were capable of refining the milled flourto a lower level of coarseness at little or no additional cost.

In conclusion, the acceptability and utilization study found that the fortified wheat flourconstituted a familiar, convenient, acceptable, nutritious and comparatively low-cost food rationfor the target population with only slight diversion. The authors recommended furtherrefinement of the milling of fortified wheat flour and suggested that efforts to extend socialawareness of its benefits be continued.

A sample of rural families were given fortified roller-mill atta to test for its acceptability relativeto chakki-mill atta. Roller-mill atta was preferred for color, flavor and texture. The smoothtexture of roller-mill atta was particularly preferred over the coarseness and grainy texture ofchakki-mill atta. No data on quality could be obtained because the fortified roller-mill atta wasconsumed within a few days of production.

2.3 EDUCATION AND PROMOTION

In tandem with the flour distribution, MOST developed and distributed educational materials toextend awareness of the benefits of using fortified wheat flour. Two posters and two pamphletswere produced in large quantities for distribution at VGD delivery points.

A training-of-the-trainers course was delivered to relevant personnel from BRAC and Proshika,the two NGOs involved in the fortification program. NGO trainers were introduced to variousmethods of information dissemination at the village level to reach VGD families in theMadaripur, Kushtia and Gaibandha areas. Subsequent monitoring showed that education andpromotion messages had been delivered as intended.

2.4 COST ANALYSIS

A cost analysis study conducted under the trial program indicates that the cost of fortifying onemetric ton (MT) of wheat flour is about 290 Taka, or $5.

At Tk203 ($3.51) per MT, the premix is the single largest component of those costs (see tablebelow). It is worth noting that since the cost of vitamin A is about 50 percent of premix cost, notincluding vitamin A would lower the cost of the premix to about Tk100 or $1.75 per MT. Thetotal cost of fortification under this scenario would be about Tk190 or $3.3.

Total annual equipment costs, including investment, maintenance, repairs and energy, areestimated at just over Tk76 ($1.31) per MT. Costs of testing (Tk7.7 or $0.13) and labor (Tk4 or$0.07) are very low.

Program Achievements

7

Fortification Cost per MT of Roller-Mill Flour

Item Cost per MTTk Dollar

Annual capital cost (depreciation and interest) 69.9 1.21Maintenance and repair 4.1 0.07Electric power 2.5 0.04Labor 4 0.07Testing materials, internal testing 5.8 0.10Periodic testing by outside laboratory 1.9 0.03Imported fortificant premix 203.1 3.51

Fortification cost per MT of flour 291.4 5.03

Fortification costs, including vitamin A, is estimated at 1.6 percent of the retail price for flour(maida) in plastic bags, suggesting that the additional cost of fortification does not appearprohibitive to consumers.

2.5 EFFICACY STUDY

In consultation with USAID/Bangladesh, MOST determined that an efficacy study todemonstrate the potential impact of wheat fortification in Bangladesh would be necessary toconvince decision-makers of the merits of an intervention on a large scale. Initially, MOSTenvisioned undertaking a double-blind randomized control trial that would not only measure thechange in selected biological indicators as a result of fortification but also test the cost-effectiveness of fortifying high-extraction wheat flour (chakki-mill flour) as compared tofortifying low-extraction wheat flour (commercial roller-mill flour).

A bid was solicited for such a study but the costs of its implementation exceeded the budgetavailable. Ultimately, the study was limited to the measurement of the impact in school-agedchildren of consuming fortified chapatis for a period of six months. To minimize costs, theInternational Center for Diarrheal Disease Control in Bangladesh prepared a proposal toundertake the study where it had the infrastructure necessary to deliver the chapatis to a captivepopulation for a six-month period.

A total of 334 children participated in the study, of which 191 received fortified atta wheat flourand 143 received non-fortified atta. Baseline data collection took place in April 2002, andparticipants' repeat measurements were collected three and six months later to assess changesbetween the two groups over time. Data included socio-demographic information (age, sex),anthropometric indices (weight-for-age, height-for-age, weight-for-height), and biochemicalvalues (serum retinol, hemoglobin, ferritin, transferrin receptor). Children in the control andfortified groups were similar at baseline on health and background characteristics.

Serum retinol concentrations were below recommended levels in a high proportion of the studypopulation at baseline. In the control group, no improvement in serum retinol over time wasobserved. Among children receiving chapatis made with fortified wheat flour, however, serumretinol showed measurable improvements. Six months after the start of the study, mean serum


8

retinol in the fortified group was significantly higher than in the control group. Separateanalyses showed that membership in the fortified group substantially reduced children's risk ofhaving inadequate retinol, of moving from a normal to deficient retinol level, and of losingretinol regardless of adequacy. Overall, the study results provide clear evidence that the use ofeven modest amounts of fortified wheat flour markedly improves vitamin A status in a period asshort as six months in populations similar to the study group.

Low hemoglobin was common in both the control and fortified groups at baseline (46 percentand 38 percent, respectively). Six months after the start of the study, no differences in meanhemoglobin or the prevalence of low values were detected between the groups. Low ferritin alsocommon in both groups at baseline (24 percent in the control group and 19 percent in thefortified group) did not change significantly over the life of the study.

Several factors may have contributed to the apparent lack of impact on children's hemoglobinand ferritin status. Children receiving fortified chapatis consumed a maximum of 3.3 mg of ironper day from the intervention. This amount may not have been sufficient to provoke measurablebiochemical changes, particularly if iron consumption from other sources were low. Theduration of the study may not have been sufficiently long to permit detectable changes to takeplace. Moreover, the iron used in the fortified wheat flour might not have been as bioavailableas had been presumed. The bioavailability of the electrolytic iron used in the fortificant wasestimated at 50 percent, relative to ferrous sulfate, but the actual value could have been lowerdue to particle size, hypochlorhydia, and other causes of iron malabsorption.

2.6 QUALITY ASSURANCE AND QUALITY CONTROL

To ensure consistent quality in the fortification of wheat flour under the trial program, and inconsideration of the potential quality assurance needs of a wider-scale fortification effort, aquality assurance manual was prepared. A part-time quality assurance specialist was hired toimplement the quality assurance task. Millers were trained in all aspects of quality assurance.The Dhaka University Institute of Food Science and Nutrition (IFSN) played an important role inthe implementation of the quality assurance program, including testing of vitamin A and iron.Record keeping at manufacturing sites was supervised by IFSN and samples were drawn fromeach batch for chemical testing.

Several critical points for maintaining quality control during the premix manufacturing and attafortification were noted:

• Testing of composite samples of fortified atta for vitamin A and iron proved to be sufficientto maintain quality. Vitamin A loss was negligible after blending and packaging of fortifiedatta.

• Loss of vitamin A after cooking of fortified atta to make chappati ranged from 10 to 15percent, which was compensated for with a 30 percent overage in the premix.

• The moisture level of the atta (above 10 percent) had to be reduced by drying of atta prior toblending of fortificants. This finding points to the conclusion that moisture management willbe a critical part of the milling process in Bangladesh, especially when the fortified atta hasto be stored for a few weeks prior to distribution.

The Wheat Flour Market and the Structure of the Milling Industry

9

CHAPTER 3

THE WHEAT FLOUR MARKET AND THE STRUCTURE OF THE MILLING INDUSTRY

3.1 WHEAT AND WHEAT FLOUR IN BANGLADESH

During 1995–2001, domestic wheat production averaged about 1.7 million MT, while importsaveraged about 1.4 million MT. Thus, total annual wheat supply in Bangladesh has recently beensomewhat over three million MT.

Although domestic wheat production expanded at an impressive rate of 7.8 percent per year, onaverage, during the past 15 years, imports declined by 1.7 percent annually during the sameperiod. Consequently, total supply did not keep pace with population growth. Whereas wheatconsumption averaged 27.4 g/person/day during 1985–89, it dropped to 19.9 g/person/day in1995–99.

There are three main categories of wheat importers in Bangladesh: the private sector, thegovernment’s Public Food Distribution System (PFDS), and foreign donors.

Foreign donations accounted for virtually all imports at the start of the 1990s. Private-sector(commercial) imports have increased steadily since 1991–92 (date at which they were firstpermitted), while the proportion of foreign donations has declined. Government commercialimports through the PFDS have been irregular and not increasing. The PFDS did not import anywheat during the 1998–1999 and 1999–2000 marketing years, and it imported only 200,000 MTduring 2000–2001. This represented about 14 percent of total wheat imports and 6 percent oftotal supply. The fact that private sector imports have been steadily increasing in the face of thedecline in foreign donations suggests that the wheat sector is becoming more of a private marketactivity in Bangladesh.

Wheat ranks second in importance after rice as a source of energy and protein in Bangladesh.Wheat consumption has recently averaged 19.9 g/year per person. Wheat provides an estimateddaily contribution of 170 calories, 5 grams of protein and 0.8 grams of fat to the average dailydiet. It also provides about 8 percent of the energy and 11 percent of the protein in the nationaldiet.

Wheat is consumed primarily in flat breads known as chapatis and parathas, although raisedbreads and pastries — often from bakeries — are also consumed in urban areas. The flat breadsare made with high-extraction flour known as atta, whereas breads and pastries are made withvarious grades of white flour, known as maida.

Wheat consumption is more important in urban areas than in rural areas. A recent survey of foodconsumption patterns in Bangladesh indicates that while overall consumption averages 54gm/day per person, the averages for the urban and rural sectors were 66.6 and 46.5 gm/day perperson, respectively. The same study reports separately for families classified as poor and non-poor. These families had an average consumption of 38.1 and 65.5 gm/day per person,respectively.


10

3.2 MILLING AND MILLING TECHNOLOGY

3.2.1 Mills

There are, essentially, two types of flour mills in Bangladesh: traditional chakki mills and rollermills.

Chakki Mills

Chakki mills are small stone-mills, usually located in rural markets and in some urban centers.Although the exact figure is unknown, it is commonly reported that there are thousands of chakkimills in Bangladesh.

Chakki mills produce whole-wheat flour. Many of these mills are imported from India. Theytypically have the capacity to grind a few tons of grain per day and operate on demand, ascustomers bring in grain for milling. The mill owner’s charge can be paid either in cash —normally Tk0.5–Tk1 per kg of wheat — or with a proportion of the resulting flour, typically 10percent. Atta that mill owners receive from customers as a milling fee becomes a primary sourceof flour in rural markets, for purchase by those without grain of their own.

Roller mills

Roller mills are the main source of flour for urban consumers. Most of those mills are located inor near urban centers, particularly in the industrial areas of greater Dhaka and Chittagong.Recent studies report that there are about 260 roller mills in Bangladesh. These mills tend to bemuch larger than chakki mills.

The daily milling capacity of the roller mills ranges from 20 MT to 150 MT of wheat, thoughnearly all have capacities over 50 MT/day. The average monthly capacity per shift is 413 MT.Assuming 25 days of operation per month at two shifts per day, average daily capacity is about33 MT. Using the same assumptions, the capacity of the largest mill is just under 100 MT/day,while the smallest is rated at only 8 MT/day.

It is believed that many of the existing mills are not operating at their rated capacities. Some areold and in need of reconditioning. In other cases, frequent disruptions in electric power supplyand high electricity rates at peak hours are prevalent. A few of the larger mills have reservegenerators available for use when electric service is interrupted.

3.2.2 Milling Technology

Roller mills vary widely in design and origin. Many are relatively old, dating back to the 1950sand 1960s. The equipment in some of these is of English and American origin, while others arefrom Switzerland. Many of the roller mills constructed during the past three decades have beenof local manufacture — copying the design of the original imports but incorporating importedrollers, many of which are from Poland. Other more recent mills are of Italian manufacture,while some smaller units are from Japan.

Cleaning, screening and sifting systems vary widely in their design. Some mills haverudimentary grain cleaning provisions. Some mills convey flour with belts and/or augers,


11

whereas others employ pneumatic conveyers. Some have unified power transmission throughshafts or belts, whereas others use individual electric motors for each machine.

Some of the smaller, locally manufactured mills are located in cramped urban settings, withlimited storage space and limited access for trucks. Some larger mills have more spaciouslayouts and ample storage facilities.

Products of the mills vary, depending on their markets and on the capacity of their equipment.All mills produce some combination of three basic items maida, atta and bran. Most millsalso produce a small amount of souji (farina), which is used for confections made for specialoccasions. Bran is added back to maida to make atta, and excess bran is sold for cattle feed.Mills with more sophisticated equipment often make two or three grades of maida with thewhitest going as their premium qua lity while other mills make two grades of atta. Attaproduced by roller mills is different from that produced by chakki mills in that it normallycontains less bran. It also varies in nutritional content, depending on the extraction rate.

Provisions for packaging also vary with the type and location of the roller mill. All millspackage a significant amount of their product in large (25–75 kg) burlap gunny sacks. These aresold to bakeries and to small vendors who re-sell in bulk to consumers, small bakeries, andrestaurants from stalls at traditional markets located throughout urban and nearby rural areas.

An increasing number of larger mills, and presumably some smaller mills, are now packing someof their flour in 1-kg and 2-kg plastic bags. Some mills have mechanical bagging machines,while others hire labor to fill the bags by hand. Some middlemen (distributors) also re-packflour from large sacks into small plastic bags. Mills have their own label and promotionalinformation — such as purity, cleanliness and healthfulness of the product — printed on eachbag.

Moisture is a critical factor in marketing flour in Bangladesh. While no comprehensive studieshave been carried out, limited testing in this fortification project indicates that the moisturecontent of flour produced by roller mills usually lies in the 13–16 percent range. At this level,flour has a storage life of only one to three weeks. Millers indicate that in order to avoid spoilageloss, distribution and marketing of flour occur shortly after it is produced, and the product isstored only for short periods of one to two weeks or less.

3.3 THE FLOUR MARKET

3.3.1 General Characteristics

Chakki mills and virtually all roller mills are privately owned. The market for wheat flour isessentially a free or open market, even though the government’s Public Food DistributionSystem (PFDS) continues to play a role in the storage and marketing of wheat itself.

The PFDS, under the Directorate General of Food, holds buffer stocks of wheat (reported to varybetween 450,000 and 750,000 MT in 2001) in government warehouses throughout the country.To maintain the buffer stock, PFDS buys from the local market and imports as necessary. Itbuys local wheat at a pre-announced procurement price and sells at a predetermined open-marketsale price. Mills are assured of a stable supply of wheat. Mills and private merchants have the


12

option of buying directly from the local market, from PFDS, or of importing wheat on their ownfollowing relatively simple procedures. PFDS does not deal in wheat flour, nor does thegovernment regulate flour prices.

Since the chakki mills operate primarily as custom mills they grind wheat for the consumptionneeds of individual customers commercial wheat marketing is mostly an activity of the rollermills. Roller mills produce mainly for the urban market, but they also sell flour to merchants andrestaurants in rural areas, particularly those within reach of the places where the mills arelocated.

Roller mills produce various grades of maida (white flour), estimated at 75-80 percent of flourproduction and atta, (whole wheat flour) at 20–25 percent. Most of the flour is still being sold inlarge burlap sacks and about one-quarter of the output is now sold in 1–2 kg plastic bags. Use ofthe plastic bags appears to be growing rapidly.

The distribution system appears to vary depending on mill size and business managementcapabilities. Some smaller mills report selling most of their flour directly from the mill door toestablished customers (bakeries and restaurants) who come to the mill to pick it up. Larger millsreport having established networks of dealers responsible for selling and delivering to their owncustomers (market stall owners, small shops, restaurants), although these mills still wholesaledirectly to larger accounts (bakeries, cookie factories, institutional buyers) on their own. Somemillers also own bakeries, or factories that produce cookies and crackers.

3.3.2 Market Size

The exact size of the market served by the roller mills is not well understood. In particular, it isnot known to what extent roller mill flour penetrates the rural market.

A study conducted under the program estimates that about one-third of the flour produced byroller mills is sold to rural consumers. Roller-mill production is estimated at about 48 percent ofthe wheat flour consumed in Bangladesh.

3.3.3 Prices

Although the market appears to be very competitive, there is a relatively wide range ofdifferences in product prices due to differences in underlying quality and the strong influence oftransportation cost.

Differences between regular maida and “special” maida, for example, are due to lower extractionrates — the special grade is typically flour produced at 65 percent extraction rate, compared to72 percent for regular flour — and to differences in wheat quality. The special maida is typicallymade with higher-quality imported wheat such as U.S. hard red winter, whereas the regularmaida is made with domestic or Indian wheat.

Transportation costs can add Tk1–2 per kg or more to the price, depending on the distanceinvolved. A mill in Chittagong reported that its wholesale price to customers from Dhaka wasTk1.75 less than what it was charging to its local customers — the difference being what Dhakabuyers demanded for sending trucks to Chittagong to pick up the flour.


13

Plastic bags add about Tk1 per kg to the wholesale price and about Tk1.50 per kg to the retailprice of the various kinds of flour.

3.3.4 Advertising

Some of the newer mills with more sophisticated equipment are able to produce a higher-qualityproduct. Some mills use higher-priced imported wheat to produce the higher quality of flourdemanded by some bakeries. Because of these product distinctions, several of the larger millsadvertise their flour.

To advertise almost certainly requires that the flour be packaged in plastic so that the consumercan be certain of its origin, otherwise advertising would not be effective. Advertising, incombination with packaging, serves to reinforce consumers’ perception that a particular brand isof higher quality. One milling company reported that its advertising costs are 8–9 percent of itstotal operating (non-grain) costs. This company is very proud of the quality of its equipment andis serious about maintaining a clean and hygienic mill — characteristics it emphasizes in itsadvertising. The company also reports that its products often retail at up to Tk4 per kg higherthan those of its competitors.

Toward a Sustainable Wheat Flour Fortification Program

15

CHAPTER 4

TOWARD A SUSTAINABLE WHEAT FLOUR FORTIFICATION PROGRAM

4.1 SUSTAINABILITY OF THE CURRENT PROGRAM

Fortified atta for the VGD program is produced in special chakki mills that have beenconstructed with equipment imported from Denmark, including micronutrient feeders. Thesemills are operated by NGOs, under the close supervision of USAID and WFP. While thisarrangement may be suitable for the limited production envisaged under the ongoing trialactivity, no mechanism is now in place that will allow production to expand beyond the VGDprogram, or to continue beyond WFP’s current programming cycle.

There are two reasons for concluding that the current approach of producing fortified flour insmall chakki mills operated by NGOs is neither institutionally viable nor economicallysustainable under a larger-scale program. First, if the fortification of wheat flour is to expand ona sustainable basis, it must be embedded in the prevailing flour production and marketingsystem. The costs of fortification must be passed on to consumers and will be reflected insomewhat higher flour prices. Since the flour market in Bangladesh is driven by a vibrant andhighly competitive private sector, any flour fortification program should build on this privatesector-based structure. Second, due to the small size of the chakki mills, their large number andtheir scattered distribution in remote locations in rural areas, they are difficult to regulate

4.2 SELECTING A SUITABLE MANUFACTURING METHOD

Milling capacity is a critical factor in determining the ease and method of fortification. Evidencefrom other countries suggests that fortification at medium (25–150 MT/day) and large mills(>150 MT/day) are most appropriate whereas the feasibility and effectiveness of fortification atsmaller stone or hammer mills have yet to be established. Large mills invariably have moremodern equipment and a higher technical capacity to integrate the fortification technology.Larger mills can also more easily amortize start-up costs and take advantage of variouseconomies of scale in production and marketing.

Chakki mills in Bangladesh typically have the capacity to grind only a few tons of grain per day,whereas the capacity of roller mills ranges from 20 to 150 MT/day. The fact that many of theroller mills are already using plastic packaging and engage in advertising based on productquality also makes roller mills a logical place to initiate commercial fortification.

Although roller mills represent the only practical means of introducing flour fortification on asustainable basis, it must be recognized that this will initially limit the access of rural consumersto the fortified product since most rural consumers obtain their flour through chakki mills. In thelonger run, as the economy develops further and as transportation improves, it is likely thatBangladesh will follow the same pattern that has been observed in other countries: roller millproduction will expand and account for an increasing share of the rural market. As that occurs,fortified flour will further extend into rural areas.


16

4.3 CHOOSING BETWEEN A MANDATORY AND A VOLUNTARY PROGRAM

The number of mills, their size and the extent to which flour milling is centralized will determinewhether a mandatory or a voluntary program is a better option. The structure of the millingindustry in Bangladesh suggests that a mandatory flour fortification program will not be realisticfor two reasons. First, the smaller mills, especially those located in rural areas, typically will nothave the capital resources needed to participate in the fortification program. Second,implementation of a quality assurance system will not be possible when most participants consistof a large number of small mills scattered throughout the country.

4.4 QUALITY CONTROL, QUALITY ASSURANCE AND MONITORING

A quality control and quality assurance system is a prerequisite to a sustainable flour fortificationprogram. Such a system requires three major components: (1) quality control (QC) and qualityassurance (QA) by producers; (2) inspection and quality audit in the production centers byinspectors from the government entity responsible for examining quality of the fortified flour;and (3) monitoring during marketing by government inspectors from entities responsible forverifying compliance.

A QC system for wheat flour fortification must be carefully thought out during planning and thensystematically implemented by government and industry as fortification is actually undertaken.This process includes raw material handling, processing, packaging, finished material handling,factory storage, distribution, warehousing and retail operations.

If the flour fortification program is to be successful, a QC system must be established from theonset. In addition to daily QC procedures, including semi-quantitative tests carried out by eachmill, an inspection system operated by government is needed to ensure that the fortificationprocess is systematically monitored and evaluated through standardized laboratory tests.Systematic monitoring will help assess whether the standards of quality and specificationscontained in the regulations are maintained at critical points of the milling and marketingsequence.

The critical importance of functioning QC and QA systems provides a strong rationale formaking roller mills the focal point of the fortification program.

4.5 PACKAGING AND LABELING

Packaging and product labeling play an important role in fortification. Some micronutrientadditives degrade with exposure to heat and UV light, and their shelf life is adversely affected byexcessive moisture. Vitamins, in particular, are affected by all these factors.

As previously noted, wheat flour produced in Bangladesh normally has a moisture content of 13–16 percent. At these levels, significant loss of micronutrients would be expected to occur iffortified flour were stored for several months. Since flour in Bangladesh is rarely stored for morethan a few weeks, micronutrient loss due to the presence of moisture is not expected to occur.

Accurate labeling is critical when fortification is voluntary, as it is expected to be in Bangladesh.When fortification is not mandatory, labeling is the only means that consumers and inspectors

Toward a Sustainable Wheat Flour Fortification Program

17

can use to distinguish fortified flour from the regular product. Information contained in labelingcan also be a useful part of promotion and consumer education.

4.6 PARTNERSHIP WITH THE PRIVATE SECTOR

Private-mill owners need to increase flour prices to offset the additional costs of fortification.Roller mill owners contacted during the trial program expressed strong interest in fortificationbecause they saw in the new product an opportunity to profitably expand their businessoperations and increase their share of a very competitive market. The fact that the larger rollermills have been expanding the use of plastic bags for packaging and promoting their productsthrough advertising fits well into the process of fortification. Messages printed on the bags, andused in the advertising programs of those companies, can readily be modified to promote thebenefits of micronutrients incorporated into the fortified flour.

A successful national wheat fortification program is a strategic alliance between the governmentand the milling industry. While government agencies define the parameters for quality control ofthe fortified flour, the private sector is responsible for their implementation.

Since sustainability is dependent on the active participation of millers and commercial flourusers, government interventions will not be effective without private sector commitment. Such acommitment will be enhanced through an active technical assistance program that provides clearinformation not only on the benefits of fortification to consumers, but also on the technicalfeasibility of the program and its cost implications for business operations.

Mill owners contacted during the program were interested in micronutrient fortification, but hadno information on costs. Such information is clearly needed to ascertain that fortification can beput into operation at a price that consumers are willing to pay. Millers also need information onthe potential adjustments that may be required in terms of plant redesign and new equipment.

4.7 CONSUMER PARTICIPATION

Creating and sustaining demand for fortified flour requires that consumers recognize the value ofsuch a product. Only after they develop an appreciation for the value of the fortified flour willthey be willing to pay the extra cost that its production requires.

For consumers to pay a premium for fortified flour, they must be informed of its nutritionalbenefits. In an economic environment driven by market incentives, private sector participantswill be willing to educate consumers on the benefits of fortified flour through advertising. Undera voluntary fortification program, the flour will be clearly labeled to show that it is fortified.Many consumers will be willing to pay a higher price for the fortified flour. The option topurchase non-fortified flour at a lower price will be available to other consumers.

Although wheat flour consumption is relatively higher in urban areas than in rural areas and forthe non-poor than for the poor, consumption patterns suggest that rural and lower-incomeconsumers will benefit from a wheat flour fortification program. The cost of fortification is onlya small fraction of flour prices, suggesting that fortification will not alter this conclusion in anyfundamental way. Cost of the packaging material may play a role in determining the cost offortified flour. However, if the flour is sold in large bulk sacks — which are not as expensive assmaller plastic bags — it will be more affordable to the poor. A study on micronutrient stability


18

and flour shelf life will be necessary to examine the feasibility of this and similar productdistribution systems.

4.8 REGULATORY ISSUES

Consumers need assurance that the fortified flour they purchase contains the appropriate level ofmicronutrients. Currently, there are no manufacturing or food processing standards inBangladesh that specify appropriate micronutrient levels for fortified flour and that outlinesuitable procedures for product sampling and verification by regulatory agencies. In addition,since existing standards for regular atta and for regular maida, and the prevailing Pure FoodOrdinance appear to prohibit the use of additives in flour, two new standards one for fortifiedatta and one for fortified maida will be required.

While modification of existing standards for maida and atta is possible, it may be more practicalto establish separate standards for fortified atta and fortified maida. Existing standards werepublished by the Bangladesh Standards and Testing Institute, the agency currently responsiblefor regulating and inspecting flour mills. To facilitate regulation and quality control, the newstandards will require the licensing of all mills that produce fortified flour. To ensure a levelplaying field for all mills, appropriate levels for each nutrient should be stated in those standards.

Beyond the Pilot Activity

19

CHAPTER 5

BEYOND THE TRIAL ACTIVITY: PROMOTING A NATIONWIDE WHEAT FLOUR FORTIFICATIONPROGRAM

5.1 PROGRESS TO DATE

In August 1999, USAID/Dhaka, initiated a trial program to examine the feasibility of reducingmicronutrient deficiency by fortifying a widely marketed staple food. The program wasdesigned and implemented by MOST, the USAID Micronutrient Program. Of the commoditiesconsidered, only wheat flour was found suitable for fortification.

Since November 2000, USAID/Bangladesh has implemented a trial wheat flour fortificationactivity under the Vulnerable Group Development (VGD) Program. The World FoodProgramme provided support to this effort. The fortified wheat flour was distributed by NGOs toVGD families. About 10,000 families participated in the program. In lieu of the usual monthlyration of 30kg of whole-grain wheat, recipients were provided 25kg of fortified wheat flour.

Program activities were designed to generate empirical data on the feasibility of wheat flourfortification on a larger scale. Several major conclusions emerged from that information:

• There is a preference among consumers for the chapati made from the fortified roller-millwheat flour in all aspects investigated including taste, texture and appearance.

• A survey based on about 1,000 households in 100 different villages confirmed consumerwillingness to use fortified roller-mill wheat flour.

• Efficacy data show a trend toward diminished vitamin A deficiency in the group thatconsumed fortified atta. However, neither group showed a positive trend with regard to irondeficiency, suggesting that the program did not provide sufficient bioavailable iron to show abiological change over the six-month trial period.

• Fortification of wheat flour in Bangladesh will require very little modification of the usualmilling process and so will be a relatively simple and low-cost operation. Fortification costsis estimated at 1.6 percent of the retail price for flour in plastic bags suggesting that theadditional cost of fortification does not appear prohibitive to consumers.

• The flour market in Bangladesh is driven by a highly competitive private sector. Asustainable program should be based on that competitive structure. For this reason, thecurrent approach of producing fortified flour in small chakki mills operated by NGOs isneither institutionally viable nor economically sustainable under a nationwide program.

• The structure of the milling industry in Bangladesh suggests that wheat flour fortificationprogram is feasible, and that voluntary fortification will be more realistic than mandatoryfortification.

5.2 NEXT STEPS

Available evidence suggests that while millers in Bangladesh are interested in fortification as ameans of adding value to their flour, a package of key interventions to support the transitionfrom the ongoing trial activity to a nationwide program will help create the conditions requiredfor the private sector to proceed. The information gathered should enable the millers to take theinitiative with the support of the Government of Bangladesh.


20

5.2.1 Developing Manufacturing Standards

Bangladesh has manufacturing standards for two types of flour, atta and maida. However, thosestandards do not specifically allow for micronutrient addition. A second constraint is that thePure Food Ordinance seems to prohibit the use of additives in flour.

Developing manufacturing standards for fortified flour will likely require the involvement of theMinistry of Public Health and Family Welfare (MPHFW), the Ministry of Food (MOF), theMinistry of Commerce, and the Ministry of Industries. It may also require involvement of theMinistry of Laws (MOL).

While modification of existing standards for maida and atta is possible, it may be more practicalto establish separate standards for fortified atta and fortified maida. Existing standards werepublished by the Bangladesh Standards and Testing Institute (BSTI), the agency currentlyresponsible for regulating and inspecting flour mills. To facilitate regulation and quality control,the new standards will require the licensing of all mills that produce fortified flour. To ensure alevel playing field for all mills, appropriate levels of each nutrient should be stated in thosestandards.

Levels of micronutrients specified in the standards for fortified flour in Bangladesh will besimilar to those used in other countries and those currently used under the trial program.However, a reevaluation of these requirements may have to be carried out based on the results ofthe efficacy study. Consideration should also be given to wheat flour consumption patterns.

5.2.2 Establishing and Maintaining Fortification Capability

Cost information developed under the program will help mill owners estimate what it will cost toembark on a fortification activity. It will also increase their confidence that fortification can becarried out at a cost that consumers can afford. However, the industry will still need guidance indetermining which equipment to procure and how to modify its mills to accommodate the newequipment. In addition, millers and supervisory personnel will need training in the operation andmaintenance of the new equipment to ensure that the micronutrients are being added inaccordance with consumer safety requirements.

Much of the technical guidance and training needed by the private mills can be acquired frommanufacturers of the fortification equipment as well as from the suppliers of micronutrientpremixes. However, additional support will be needed from a local organization that can offerindependent technical advice and training on an as-needed basis.

The Institute of Nutrition and Food Science (INFS) of Bangladesh University has a staff of 35teachers and 75 technical experts, with a mandate to support the food processing industry. INFShas indicated its willingness to establish a Food Fortification Unit (FFU) that would providetechnical support and training to wheat flour millers, as well as to other entrepreneurs willing toexplore similar fortification opportunities. Staff to be assigned to FFU would include a cerealtechnologist and an industrial engineer who specializes in food processing.

While INFS is familiar with wheat fortification because of its involvement in the ongoing trialproject, its FFU staff would need additional training in more specific aspects of fortification,

Beyond the Pilot Activity

21

including maintenance of fortification equipment. Trained personnel would become a source ofexpertise available to the flour milling and other food industries on a permanent basis.

Discussions with U.S. universities indicate that the required training can be provided in a one-week course. To ensure that FFU has sufficient depth in fortification technology, it isrecommended that training be provided to both an industrial engineer and a food scientist. Suchtraining can be combined with training in quality control.

5.2.3 Developing Adequate Quality Control and Quality Assurance

To implement a sound quality control system for flour fortification, it is recommended that aselected number of Bangladeshi specialists be trained in quality control procedures. It isimportant that those specialists receive training in both ingredient application and quality control.Such training should include information on related topics such as flour additive systems,additive-system maintenance and laboratory tests for micronutrients.

Training in quality control and quality assurance can be combined with training to establish andmaintain a fortification capability. One option would be to train food technologists from theFood Fortification Unit of the Institute of Nutrition and Food Science at Dhaka University. Thetechnical services of those specialists would be made available to millers needing assistance withquality control, as well as to the government entity responsible for implementing the QA system.The university’s laboratories would be made available on a fee-for service basis to support thequality control and quality assurance system.

5.2.4 Enforcement

A fortification program requires an enforcement system to validate claims and levels offortification. Regulatory monitoring is performed at two levels: factories and retail stores. Thegovernment authority will ensure that technical standards are fulfilled. Monitoring at the retaillevel commercial inspection will be used to confirm presence and quality of the fortifiedcommodities at that level.

5.2.5 Program Monitoring and Evaluation

A major objective of program monitoring is to confirm that the fortified food is indeed reachinga given proportion of consumers. While regulatory monitoring shows whether the fortifiedproduct is delivered to consumers in the appropriate amount and with the desired characteristics,household/individual monitoring and evaluation help policymakers document consumption andcoverage to decide whether an on-going intervention should be continued in its current form orshould be adjusted. Here, estimation of micronutrient intake and coverage are undertaken.Under certain circumstances, biological outcomes may also be evaluated.

5.2.6 Developing a Public-Education Campaign

Under voluntary fortification, it is expected that the private sector will play a primary rolethrough advertising and other consumer marketing techniques to compete for consumerpreference. However, since fortification is a new concept to government officials and mostconsumers in Bangladesh, a promotion campaign by an outside organization will be warranted.A well-designed public-education effort is therefore essential to the successful introduction of


22

large-scale wheat flour fortification in Bangladesh. Promotional activities must be directed atcognizant units of government, the milling sector and consumers.

Experience under the trial program, and under an earlier effort to introduce the use of fortifiedflour under the FFE program, shows that GOB officials in key positions often have limitedunderstanding of fortification and its potential value to the country. Similarly, despite theenthusiasm of some mill owners, many in the private milling industry have little understandingof fortification and its benefits and so will be reluctant to proceed without further knowledge.

Fortification is a new concept to most consumers in Bangladesh. In the trial program, USAIDand WFP have overcome the lack of knowledge by making provisions to educate participatingVGD households about the benefits of fortified flour. Educational activities are based on avariety of training materials, including professionally designed posters placed in classrooms andrural centers.

Although the cost of fortified flour is not expected to be much greater than that of ordinary flour,consumers will need to be well informed about the benefits of the new product before they canbe expected to purchase it. This is all the more important since, at the initial stage, consumers areunlikely to notice the difference between fortified and ordinary flour or have any knowledge ofthe potential benefits that fortified flour may have.

Consumer acceptance will be greatly enhanced through an information dissemination programsponsored by government authorities and publicly supported by nationally renowned localscientists with established knowledge in nutrition.

The Bangladesh Major and Compact Flour Millers’ Association, headquartered in Dhaka, is apotentially good channel for educating and encouraging millers. The larger and more progressiveentrepreneurs are already engaged in advertising to establish a recognized brand for their flour.Those among them who have already shown interest in fortification are the most likely toproceed with it — given additional information and initial support. Advertising programs bysuch mills can be an important source of consumer information, particularly if their advertising isconsistent with clearly articulated public health statements made by recognized publicauthorities.

With appropriate support, INFS and its new FFU would become the focal point of a series ofpromotional activities to initiate production of fortified flour in roller mills. Such initiativeswould preferably be implemented in collaboration with the millers’ association or with a groupof independent millers who have demonstrated a strong desire to participate in the fortificationprogram. To succeed, such an effort will require the support of a professional public relations oradvertising agency.

23

Appendix A

LIST OF STUDIES, TECHNICAL REPORTS AND TRIP REPORTSPREPARED UNDER THE PROGRAM

Allen, K. September 1999. Bangladesh Trip Report. MOST, the USAID Micronutrient Program.

Hussain, AKM Ghulam, and Mohammad F. Khan. 2002. Acceptability and Utilization ofFortified Atta Distributed Under the Pilot Project for Atta Fortification. Asian Institute, AsianUniversity of Bangladesh. MOST, the USAID Micronutrient Program.

Hyder, K. Bangladesh Trip Report. June-July, 2002. MOST, the USAID Micronutrient Program.

Hyder, K. Bangladesh Trip Report. January-February 2002. MOST, the USAID MicronutrientProgram.

Hyder, K. Bangladesh Trip Report. October-November 2001. MOST, the USAID MicronutrientProgram.

Hyder, K. Bangladesh Trip Report. June-July 2001. MOST, the USAID Micronutrient Program.

Hyder, K. Bangladesh Trip Report. March 2001. MOST, the USAID Micronutrient Program.

Hyder, K. and O'Sullivan, J. Bangladesh Trip Report. November 2000. MOST, the USAIDMicronutrient Program.

Hyder, K. May 2000. Bangladesh Trip Report. MOST, the USAID Micronutrient Program.

Hyder, K. August 1999. Bangladesh Trip Report. MOST, the USAID Micronutrient Program.

Knight International, 2001. Quality Control System for Fortification of Wheat Flour withVitamin A and Iron in Bangladesh. Prepared for MOST, the USAID Micronutrient Program.

Malek, M.A., and Aminul H. Bhuya, 2001. Report on Organoleptic Test of Fortified Atta.Institute of Nutrition ad Food Science, University of Dhaka, Bangladesh. Prepared for MOST,the USAID Micronutrient Program.

Rahman AS, Wahed MA, Alam MS, Ahmed T, Ahmed F, Quaiyum MA, and Sack DA, 2003.Randomized, Double-blind Controlled Trial of Wheat Flour Fortified with Vitamin A and Iron inImproving Vitamin A and Iron status in Healthy, School Aged Children in Rural Bangladesh.Prepared for MOST, the USAID Micronutrient Program by the Centre for Health and PopulationResearch of the International Centre for Diarrhoeal Disease Research, Bangladesh.

Rassas, Bechir and J. Fitch. July 2002. Wheat Flour Fortification in Bangladesh Cost Analysisand Sustainability Considerations. MOST, the USAID Micronutrient Program.

Appendix B

STUDY TITLE: RANDOMIZED, DOUBLE-BLIND

CONTROLLED TRIAL OF WHEAT FLOUR (CHAPATI)FORTIFIED WITH VITAMIN A AND IRON IN

IMPROVING VITAMIN A AND IRON STATUS INHEALTHY, SCHOOL AGED CHILDREN IN RURAL

BANGLADESH

1

Final reportMay 30, 2003

Study title: Randomized, Double-blind Controlled Trial of WheatFlour (Chapatti) Fortified with Vitamin A and Iron in ImprovingVitamin A and Iron status in Healthy, School Aged Children in RuralBangladesh.

Rahman AS, Wahed MA, Alam MS, Ahmed T, Ahmed F, Quaiyum MA, andSack DA

Study was sponsored by the Most Project

Introduction

Other than iodine deficiency which posses risk to more than a billion peopleworldwide, lack of vitamin A and iron and consequences of their deficiencies are thetwo most recognized micronutrient related global public health problem.1 In additionto its effects on xeropthalmia, adequate vitamin A nutriture reduces up to a quarter toone-third of infection related children mortality.2,3 The consequences of irondeficiency and iron deficiency anemia include reduced physical activity, impairedcognitive function and brain metabolism and reduced immunocompetence. 1

The latest estimate suggest that about 3 million children are still suffering fromxeropthalmaia and another 150-200 million are sub-clinically vitamin A-deficient;mostly (32-60 million) in South Asia.4 In Bangladesh, xeropthalmia in preschoolchildren has been reduced from 3.5% in 182-83 to 0.6% in 1997-98.5 However, 22%of preschool children were still sub-clinically deficient with serum retinol <0.7µmol/l.5 Among school-age children, 22% had serum retinol level <0.7 µmol/l and74% <1.05 µmol/l.5

Globally, more than 3 billion people are suffering from anemia and iron deficiencyand this is affecting the development of half of those growing up in Africa and Asia.All age groups and sexes are affected with anemia and iron deficiency disorders inBangladesh. Among school-age children (6-14 years), 51.4% of rural and 42% ofurban had hemoglobin level <11g/dl.5

Food fortification is a type of food processing in which an appropriate food (vehicle)is supplemented with essential nutrients, whether or not it is normally contained in thefood, at a level (usually 25 – 50% RDA) that does not cause any change in itsphysical, chemical or biological properties. Food fortification, has been identified bythe World Bank as among the most cost effective and sustainable strategies to preventor correct micronutrient deficiencies.6

Fortification of foods such as margarine, milk, and bread with vitamin A has longbeen a practice in Western countries. However, at present, there are many successfulexamples of fortification programs in developing countries. Until 1998, there were 17countries in Latin America that fortify foods with one or more micronutrients.7 InGuatemala, fortification of sugar with vitamin A substantially improved vitamin A

2

status of preschool children.8 In Venezuela, consumption of fortified flour (maize,wheat) has been shown to improve iron status compared to a pre-intervention period.9

Vitamin A status of the low and marginally deficient children has been improved afterconsuming vitamin A fortified pandesal (bun) in the Philippines.10

Until now, no cereal fortification program has been in place nor was one ever tested inBangladesh. Rice, the major staple in Bangladesh is extremely difficult to fortify withmicronutrients. Wheat is the second staple food in Bangladesh. Domestic production,which is about 20% of the total consumed, and consumption have been increasing inrecent years.11 Cereals, which are consumed in powder form, are technically morefeasible to fortify with micronutrients and cost effective than cereals which areconsumed whole. Moreover, wheat is relatively more centrally processed than riceprocessing in Bangladesh. Wheat flour, therefore, had been selected as a potentialvehicle to be fortified with micronutrients in this study.

The present study evaluated the efficacy of daily consumption for six months of twochapattis made with wheat flour fortified with vitamin A, iron and other vitamins andminerals in improving serum retinol and/or iron status in school aged children in ruralBangladesh. The amount of chapatti were designed to provide 30 to 60% of the RDAof several micronutrients for the children and the trial assumed that the childrenwould consume their normal daily diet in addition to the chapattis.

Methodology

Design: This was a cluster-randomized, double-blind, controlled trial in a rural area inMirsarai (sub-district) under Chittagong district in southern Bangladesh. Twochapattis prepared from fortified or unfortified wheat flour (100g) were consumed byapparently healthy school aged children (6-15 years of age) daily for 6 months. Thecomposition of the fortified flour and contribution of the fortificant micronutrients toRDA of this age group is shown in Table 1. The objective of this efficacy study wasto detect an impact of consuming fortified chapatti by the study children, primarily,on changes in their vitamin A status reflected in serum retinol level and on iron statusas reflected by hemoglobin, serum ferritin, serum transferrin receptor concentrationsduring the six month period. Blood samples were collected prior to the start offeeding, three months later and six months later at which time the feeding wasstopped.

3

Table 1: Levels of fortificants per kg wheat flour and contribution from chapatticonsumption (100g flour) to micronutrient requirements of children

Contribution of flour (100g) to requirements of children,6-15 years old

Nutrient Level in flour(per kg)

Nutrient consumed(per day)

RDA %RDA

Vitamin A1 10,000 IU 212 µg2 400 – 600 µg 53 – 35%Iron3 66.0 mg 3.3 mg 4 10 – 15 mg 33 – 22%Thiamin (vit. B1) 6.4 mg 0.64 mg 1.2 mg 53%Riboflabin (vit B2) 4.0 mg 0.40 mg 1.0 mg 40%Folic acid 1.5 mg 0.15 mg 0.25 – 0.4 mg 60 – 37.5%Zinc oxide 33.0 mg 3.3 mg 10 mg 33%Niacin as niacinamide 53.0 mg 5.3 mg 10.4 – 12.5 mg 51 – 42%

1Retinyl palmitate, USP-FCC2 accounting for a loss of 30% during storage and chapatti preparation3 As electrolytic elemental iron, USP-FCC4 Accounting for 50% bioavailability compared to ferrous sulfate

Intervention area: The study area is situated in the southeastern part of Bangladesh,which is 365 kilometers away from the capital Dhaka. Seven unions (immediate lowerlevel of sub-district) out of 16 of Mirsarai (Figure 1) with a population of about172,544 were selected for the study. The area has been a field area of theInternational Centrre for Diarrhoeal Disease Research, Bangladesh which hasmaintained demographic surveillance in the area since 1995. A map of the area isshown on Figure 1.

4

Figure 1: Intervention Area

·

>%

DHUM

OSMANPUR

SAHERKHALI

ICHHAKHALI

HINGULI

ZORWARGANJ

KATACHHARA

MIRSARAI

MITHANALA

MAGHADIA

MAYANI

DURGAPUR

KHAIYACHARA

HAITKANDI

WAHEDPUR

KARERHAT

Selected unions are highlighted

5

Unit of randomization: A total of 4875 baris (a bari is composed of a few adjoininghouseholds, usually 5 – 6 and with a population of about 30 – 35) were enlisted in theselected 7 unions and out of them 48 baris were randomly selected for the study.

Sample size: Sample size was estimated by taking into account the mean andstandard deviation (SD) of serum retinol and ferritin concentrations. Unfortunately,there was no data on serum retinol or ferritin distribution in this age group in ruralBangladesh on which to base a sample size. However, in a trial in Guatemala,8 themean+ SD of serum retinol concentrations were 29.2+10.2 µg/dl and 34.2+9.5 µg/dlbefore and after 1 year of supplementation with sugar fortified with vitamin A. Withthis level of change, 83 subjects were required in each group (95% significance levelwith a power of 90%).

Sample size was again estimated by taking into account the mean and standarddeviation (SD) of serum ferritin concentrations. In a trial in Venezuela, the mean+SDof serum ferritin concentrations were 18.01+13.8 µg/l and 25.2+15.3 µg/l before andafter supplementation with maize and wheat flour fortified with iron.9 With this levelof change, 87 children were required in each group (95% significance level and apower of 90%).

Considering the greater of the two estimates (87 subjects), the calculated sample sizehad been doubled to 175 in each group to account for cluster and dropout effects.

Sample size was estimated by using the formula:

2(Sd)2 x factor for á, â(WD)2

Where, SD is the standard deviation and WD is the worthwhile difference between themeans.

Study sample: Three hundred fifty two (352) apparently healthy school-age children(6 – 15 years of age) were enrolled from the selected baris to be included in the study.Analysis was carried out with 334 children who completed the study (191 in fortifiedand 143 in nonfortified control group). 18 children were excluded (5 migrated out, 9refused to give blood, 1 dropped from the study due to no chapatti consumption,blood could not be drawn from 2 children and 1 was absent during final bloodcollection).

Orientation workshop/meetings: Before the intervention started, workshops andmeetings were organized with the participation of local and district health officialsand elected or non-formal local leaders to orient them about the intervention andseeking their opinions and cooperation for the study.

Pretest: A one month pretest was conducted in non-intervention unions of Mirsarai toestablish procedures and preparation of the field settings, including handling, storageof wheat flour, making of chapattis, and observing chapatti consumption pattern.

6

Result of the pretest: The pretest revealed that 2 chapattis made from 100g flourwere consumed by all (but one) of 43 participants, 6-15 years of age and was wellaccepted when served with a condiment [halwa made of suji (semolina) and sugar].

Flour fortification and quality assurance: The wheat flour was produced by aflourmill in Dhaka and fortified as a “batch process” at a pharmaceutical companythat is also located in Dhaka. The fortifying company maintained the qualityassurance of the flour. Samples of flour and chapatti from intervention baris were sentto a laboratory from time to time to the Institute of Nutrition and Food Science, DhakaUniversity to test for micronutrient (vitamin A and iron) content. The results of theanalyses revealed that about 100% and 90% of vitamin A content of the wheat flourand chapatti respectively were retained at the time of laboratory testing.

Packaging, supply and distribution of flour: Packaging of flour (fortified ornonfortified) in polyethylene bags (each bag contained 700g flour) printed withintervention specific information and batch number was done at the fortifyingcompany and sent to the intervention site on an average in every two weeks. Thecartons of flour bags were kept in a well ventilated room at the ICDDR,B Mirsaraisite office before distribution. The atta (flour) was distributed beginning March 31,2002 by the study staffs once in a week throughout the intervention period for 6months. To prevent sharing of chapattis of the participants by other members of abari, the same amount of flour was also allocated for other members of that barithroughout the intervention period. All residents of the bari were eating the chapattisalthough data on consumption were collected only from the selected children enrolledin the study. To ensure consumption compliance of chapatti by the participants,condiments (suji/semolina and sugar to prepare Halwa) were also supplied each weekalong with the flour.

Preparation and monitoring of chapatti consumption: A total of 65 bari motherswere selected to prepare chapatti and halwa daily to distribute these among theparticipating children. The chapattis were made from the flour preferably with hotwater. Two chapattis were made from 100g flour for each participant. A measuringcup that filled with 100g flour was supplied to the bari mother to ensure that exactamount of flour was used to prepare the required number of chapatti. A different bariperson (not the bari mother) was assigned to monitor chapatti consumption by theparticipants during feeding session in the morning and the bari person documented thenumber of chapatti consumed by each participant in a format supplied by the studystaff. Study staff visited the baris at least once in a week to monitor chapatticonsumption during feeding sessions and collect the filled formats from the bariperson after verifying it through interviews with bari person, participants and themothers. The chapatti-feeding program ended with final blood collection after 6months.

Data collection: Baseline blood samples were drawn during the period from March31. 2002 to April 11, 2002 from 352 children. The mid-point (after 3 months) bloodsamples were collected from 343 subjects during the time period from June 30, 2002to July 17, 2002. This represented 97% of those from whom we had baseline bloodsamples. The end-point (after 6 months) blood samples were collected during the timeperiod from September 30, 2002 to October 14, 2002. This represents 95% of thosefrom whom we had baseline blood samples.

7

Weight and height measurements at each point of data collection were converted toweight-for age and height-for-age indexes, expressed as z scores by using theinternational reference population.12

Biochemical analyses: About 4.5 ml blood was collected from the participatingchildren in each point by venipuncture using aseptic technique, and an aliquot wasimmediately put into a vial covered with aluminum foil to prevent exposure to lightand kept in a rack at room temperature until clotted. Another aliquot was put in a tubecoated with EDTA for the estimation of hemoglobin. All the samples weretransported to a nearby peripheral laboratory set at Mirsarai (ICDDR,B site office) forcentrifugation. Blood and separated serum samples were transported to the NutritionalBiochemistry Laboratory of ICDDR,B in Dhaka. Hemoglobin was estimatedimmediately thereafter and serum was stored at – 200C until analysis.

Hemoglobin concentration in whole blood was determined by methemoglobinmethod. This is a quantitative and colorimetric technique in which total hemoglobin atalkaline pH is rapidly converted to a cyano derivative when treated with K3[fe(CN)6],which is determined by its absorbance at 530-550 nm. The color intensity at thiswavelength is proportional to total hemoglobin concentration.13 Serum retinol wasdetermined by high performance liquid chromatography (HPLC). 100 µl serum wasdeproteinized with methanol containing 50 mg/dl retinyl acetate as an internalstandard, and retinol extracted into hexane. The hexane layer was transferred to aclean vial, evaporated under nitrogen stream, redissolved in mobile phase and injectedonto the HPLC column. Retinol was separated by reverse-phase HPLC using a C-18column, and detected at 325 nm. Two plasma pool samples with assigned value setagainst a standard serum from National Institute of Standard Technology (NIST) wererun with each lot of samples and the concentration of retinol calculated based on theknown concentration of retinol in the pool samples.14, 15, 16 Serum ferritinconcentration was measured by immunoturbidimetric method using a commercial kit(Tina-quant Ferritin, Roche diagnostics, Mannheim, Germany). Serum transferrinreceptor concentration was measured by immunoturbidimetric method using acommercial kit (Tina-quant Soluble Transferrin Receptor (sTfR), Roche Diagnostics,Mannheim, Germany)

Cut-off levels to define deficiencies:For the purpose of categorizing the children into sub-clinical and sub-optimal vitaminA deficient, serum retinol levels <20µg/dl and <30µg/dl were taken as cut-off pointsrespectively. To define anemia in this age group, cut-off point of hemoglobin level<12g/dl, as used by the World Health Organization. Iron deficiency was defined byserum ferritin level <20ng/ml and / or transferrin receptor level >5µg/ml.

Statistical analysis:

Data on age, weight and height were entered in Epi-Info 2000 software to calculate Z-scores and all data were entered in Microsoft Access. Data were analyzed by SPSS10.0 for Windows. A p value<0.05 was considered as statistically significant.Distribution of variables at baseline, 3 months and 6 months was examined by onesample Kolmogorov-Smirnov test (non-parametric test). Data for normally distributed

8

variables are reported as means±SDs with 95% CIs; data for non-normally distributedvariables are presented as medians with ranges. Group baseline characteristics weresummarized and comparability of variables between groups at baseline, 3 months and6 months was examined by unpaired t-test for normally distributed variables and byMann-Whitney (non parametric) test for non-normally distributed variables. Withingroups comparability was assessed by paired t-test for normally distributed variablesand by Wilcoxon Signed Ranks test for non-normally distributed variables. Chi-square test was used to compare two proportions and to examine trend in proportionswithin groups (more than two proportions). To examine the proportion of pairedchildren improved from subclinical and suboptimal level of serum retinol at baselineto six months subgroup analysis was done. The compliance of chapatti consumptionbetween the two groups during the intervention was also compared.

Results:

The characteristics of the 2 groups of children are compared in Table 2. The fortifiedand control groups were well-balanced with respect to age, sex, weight, height,including hemoglobin, serum retinol, serum ferritin and serum transferrin receptorlevels. Children were marginally nourished, as evidenced by average weight-for-height z scores of –1.84 and –1.53 and height-for-age z scores of –1.72 and –1.4 forthe fortified and control groups, respectively. The mean weight-for-age and height-for-age z scores were significantly lower in the fortified group than the control groupat baseline.

Table 2: Baseline characteristics of the study children

Characteristics Fortified group(n=191)

Control group(n=143)

Age (years)2 10 (6, 15) 10 (6, 15)% of male 49.7 51.7Weight (kg)2 24.2 (11, 47.7) 24.4 (13.6, 49.9)Height (cm)a 129.63 + 15.33

[127.45,131.81]3131.36 + 16.71[128.62,134.1]3

Z-weight-for-agea,1 -1.84 + 0.81[-1.96, -1.72]3

-1.53 + 0.76[-1.66, -1.40]3

% with Z-weight-for-age <-2SD 47.14 30.1% with Z-weight-for-age <-3SD 5.2 1.4Z-height-for-agea,1 -1.72 + 1.2

[-1.89, -1.55]3-1.4 + 1.15

[-1.59, -1.21]3

% with Z-height-for-age <-2SD 42.44 23.8% with Z-height-for-age <-3SD 11.0 7.71.4Hemoglobin (g/dl)a 12.25 + 0.9

[12.12, 12.38]312.11 + 0.93

[11.96, 12.26]3

Serum retinol (µ/dl)a 27.62 + 7.41[26.57, 28.67]3

28.02 + 8.16[26.68, 29.36]3

Serum ferritin2(ng/ml) 33.2 (6, 165) 33.0 (3, 116)Serum transferrin receptor2(µg/ml) 3.56 (1.9, 8.9) 3.53 (2.2, 9.4)

a Mean ± SD1 Significantly different between fortified and control groups at baseline, p<0.05 (unpaired t-test)2 Median (range)3 95% CI4Significantly different from control group, p<0.05 (chi square for proportion test)

9

The chapatti consumption compliance in both groups is compared in Table 3. Thenumber of chapatti (mean ± SD) consumed by the fortified and control groups are351±21 and 355±16 respectively of a possible 366 chapattis during the 183 days ofthe intervention. Equal or more than 90% (> 329 chapattis) compliance was achievedby the 89 and 93% of the children in fortified and control groups respectively.

Table 3: Number of chapattis consumed during the intervention by 2 groups 1

Fortified group (n= 191)

Control group (n= 143)

Maximum number of chapatti provided2 366 366Total number of chapatti consumed over 6 months 350.89+ 20.753 354.69+ 16.433

Chapatti intake/d 1.92+ 0.11 1.94+ 0.09% distribution of chapatti compliance by the childrenduring intervention

> 90% (> 329.4 chapattis)80 – 89.99% (292.8 – 329.36 chapattis)70 – 79.99% (256.2 – 292.76 chapattis)< 70% (< 256.2 chapattis)

89.07.92.11.0

93.05.61.4-

1 No significant difference between the groups (chi-square test for proportion)2 Computed by multiplying the total number of days of the intervention (i.e. 183) and the number ofchapatti provided to each child daily (i.e. 2 chapattis)3 Mean + SD

The impact of fortified wheat on vitamin A status is shown in Table 4. The meanserum retinol levels were similar between the two groups at baseline, but at 6 monthswas significantly higher in the fortified group. Twenty-six children (13.6%) in thefortified group and 22 children (15.4%) in the control group had subclinical vitamin Adeficiency (serum retinol < 20 µg/dl) at baseline. At 3 and 6 months, subclinicalvitamin A deficiency was significantly reduced in the fortified group (7.9 and 7.4%)compared to the control group (16.2 and 22.5%). Within groups, the trend ofreduction of subclinical deficiency over time was only significant in the fortifiedgroup.

Table 4: Impact of fortified wheat on vitamin A status

Mean serum retinol,µg/dl (95% CI)

Number Fortified group Number Control group

Baseline 191 27.62[26.57, 28.67]

143 28.02[26.68, 29.36]

3 months 189 30.612

[29.33, 31.89 ]142 29.812

[28.16, 31.46 ]6 months 190 30.251,2

[29.18, 31.30 ]142 27.033

[25.64, 28.42 ]% <20µg retinol/dl 6

Baseline 191 13.65 (26) 143 15.4 (22)3 months 189 7.94 (15) 142 16.2 (23)6 months 190 7.44 (14) 142 22.5 (32)

1 Significantly different from control group, p<0.01 (unpaired t-test)2 Significantly different from baseline, p<0.01 (paired t-test)3 Significantly different from 3 months, p<0.01 (paired t-test)

10

4 Significantly different from control group, p<0.05 (chi square for proportion test)5 Trend is significant at 5% level from baseline to 3 months and 6 months (chi square for trend)6 Numbers are shown within bracket

The mean concentration of hemoglobin and the prevalence of anemia (hemoglobin <12g/dl) in the fortified and control groups were similar at baseline as shown in Table5. The evaluation for an impact of fortified flour on hemoglobin status is also shownin Table 5. There was no demonstrable effect of fortification or chapatti consumptionon average hemoglobin levels at 3 or 6 months, nor was there a reduction in theproportion of children who had anemia.

Table 5: Impact of fortified wheat on hemoglobin (Hb) status

Mean Hb, g/dl(95% CI)


Baseline 189 12.25(12.12, 12.38)

142 12.11(11.96, 12.26)

3 months 188 12.13a

(12.08, 12.18)143 12.07

(11.94, 12.22)6 months 188 12.28b

(12.14, 12.42)141 12.31b,c

(12.16, 12.46)

% <12g/dl d

Baseline 189 37.6 (71) 142 45.8 (65)3 months 188 41 (77) 143 42.7 (61)6 months 188 37.8 (71) 141 35.5 (50)

a Significantly different from baseline, p<0.05 (paired t-test)b Significantly different from 3 months, p<0.05 (paired t-test)c Significantly different from baseline, p<0.05 (paired t-test)d Numbers are shown within bracket

The impact of fortified wheat on iron status is shown in Table 6. Although there wassome increase in the serum ferritin at three and six months, this was seen in bothgroups and there was no significant difference between the fortified and unfortifiedgroups at six months. The proportion of subjects with low serum ferritin levels (<20ng/ml) was similar at baseline (19.4 vs. 24.5%), 3 months (15.3 vs. 15.4%) or 6months (18.8 vs. 18.9%) in both the groups. The prevalence of low serum ferritin didnot decrease at six months in either of the groups.

Mean serum transferrin receptor levels were similar in the two groups at baseline anddid not change in either group at 3 months and 6 months. The proportion of subjectswith high transferrin receptor levels (> 5 µg/ml) was significantly lower in thefortified than the control group (4.2 vs. 10.5) at baseline. However, there was nodifference in this proportion at 3 or 6 months between the groups and there was not asignificant change over time within the groups.

11

Table 6: Impact of fortified wheat on iron status

Median serumferritin1 (ng/ml)


Baseline 191 33.2 143 33.03 months 189 34.5 143 38.32

6 months 191 42.7 2,4 143 39.8% <20 ng/mlBaseline 191 19.4 143 24.53 months 189 15.3 143 15.46 months 191 18.8 143 18.9Median serumtransferrinreceptor1 (µg/ml)Baseline 191 3.56 143 3.533 months 189 3.75 143 3.682

6 months 191 3.592 143 3.58% >5 µg/mlBaseline 191 4.23 143 10.53 months 189 9.5 143 14.06 months 191 8.4 143 14.0

1 No significant difference between the groups regarding serum ferritin and transferrin receptor levels(Non parametric Mann-Whitney test)2 Significantly different from baseline, p<0.05 (Non parametric Wilcoxon Signed Ranks test)3 Significantly different between the groups, p<0.05 (Chi square for two proportion test)4 Significantly different from 3 months, p<0.05 (Non parametric Wilcoxon Signed Ranks test)

The correlation between serum ferritin and transferrin receptor at baseline, 3 monthsand 6 months is shown in figure 2. The correlation was found negative between thesetwo variables at all the time points but significant at baseline and 6 months only. Thecorrelation co-efficient has increased about 2 times at 6 months than baseline.

12

Figure 2: Correlation between serum ferritin and transferrin receptor

Correlation between Serum ferritin and Serum transferrin receptor at baseline

0123456789

10

0 20 40 60 80 100 120 140 160 180

Serum ferritin

Ser

um tr

ansf

errin

rece

ptor

r= -0.165 (p<0.01)

Correlation between Serum ferritin and Serum transferrin receptor at 3 months

0123456789

10111213

0 20 40 60 80 100 120 140 160 180 200 220 240 260

Serum ferritin

Ser

um tr

ansf

errin

rece

ptor

r= -0.042 (p=0.444)

Correlation between Serum ferritin and Serum transferrin receptor at 6 months

0123456789

101112

0 20 40 60 80 100 120 140 160 180 200 220 240 260

Serum ferritin

Ser

um tr

ansf

errin

rece

ptor

r= -0.305 (p<0.01)

13

Fate of children with low serum retinol and / or iron

The proportion of the children who improved from subclinical (serum retinol<20µg/dl) or suboptimal (serum retinol <30µg/dl) vitamin A deficiency are shown inTable 7. In the fortified group the serum retinol of 20 children (76.9%) out of 26 whowere had baseline levels of retinol <20µg/dl had an increase above the cut-off level atsix months, compared to 6 children (27.3%) of 22 in the control group (p<0.01).Similarly the proportion of children with retinol levels <30µg/dl decreased in thefortified group (42% compared to 21%, p<0.01).

Table 7: Percent of paired children improved from subclinical (serumretinol <20µg/dl) and suboptimal (serum retinol <30 µg/dl) vitaminA deficiency

Number Fortified group Number Control groupNo. of children < 20µg/dl at baseline 191 26 (13.6%) 143 22 (15.4)Proportion of children who had increased to > 20µg/dl at 6 months

26 20 (76.9)1 22 6 (27.3%)

No. of children < 30 µg/dl at baseline 191 127 (66.5%) 143 90 (62.9%)Proportion of children who had increased to > 30µg/dl at 6 months

127 53 (41.7%)1 90 19 (21.1%)

1 Significantly different between the groups at 6 months, p<0.01 (Chi square for two proportion test)

No significant difference was observed between the groups regarding the proportionof children with hemoglobin <12g/dl who improved during the intervention as shownin Table 8.

Table 8: Percent of paired children improved from anemia (Hb <12g/dl)1

Number Fortifiedgroup

Number Controlgroup

No. of children, Hb < 12g/dl atbaseline

189 71 (37.6%) 142 65 (45.8%)

Proportion of children with anemiaat baseline whose Hb increased to >12 g/dl at 3 months

69 18 (26.1%) 65 18 (26.9%)

Proportion of children with anemiaat baseline whose Hb increased to >12 g/dl at 6 months

68 22 (32.4%) 63 22 (34.9)

1 No significant difference between the groups at p<0.05 (Chi square for two proportion test)

Table 9 shows an analysis limited to those children with hemoglobin < 12 g/dl as wellas low serum ferritin or a high transferrin receptor (iron deficiency anemia). Thoughnot statistically significant, there were fewer anemic children with iron deficiency.

14

Table 9: Percent distribution of anemic children (Hb < 12g/dl) with serum ferritin <20 ng/ml andtransferrin receptor > 5µg/ml at baseline, 3 months and 6 months1

variables round number Fortifiedgroup

number Controlgroup

Baseline 71 17(23.9%) 65 17 (26.2%)3 months 77 10 (13.0%) 61 11 (18.0%)

Serum ferritin <20ng/ml

6 months 71 12 (16.9%) 50 11 (22.0%)Baseline 71 6 (8.5%) 65 10 (15.4%)3 months 77 11 (14.3%) 61 14 (23.0%)

Serum transferrinreceptor > 5µg/ml

6 months 71 11 (15.5%) 50 12 (24.0%)

1No significant differences in the proportion at any point of time between or within the groups ata level of p<0.05

The results of backward multiple regression analysis in a repeated style is given in theTable 10. Hemoglobin level was observed significantly higher among the older andmale children than younger and female children, respectively, in the fortified andcontrol group as well as combined group.

In the combined group, age and fortified group had a significant positive impact onthe serum retinol level and male children had lower retinol levels than female. Whenthe model was run separately, age was found significant in both fortified and controlgroups but round was found significant only for fortified group and sex (m) was foundsignificant only for control group.

Age, sex and group had no significant impact on serum ferritin levels when the modelwas run over combined or the groups separately. But over time serum ferritin levelsincreased significantly in all situations. Older children in the fortified group had betteriron status than younger children when transferrin receptor was considered.

15

Table 10: Effect of age, sex, group and round on outcome variables (results from repeatedmeasure multiple regression analysis)1

Both groups combined Fortified group Control groupVariablesâ P value CI â P value CI â P value CI

Hemoglobin:Age 0.117 0.000 0.097, 0.136 0.133 0.000 0.106, 0.160 0.097 0.000 0.068, 0.127Sex (m) 0.210 0.000 0.101, 0.320 0.187 0.000 0.042, 0.333 0.228 0.007 0.061, 0.199Group (f) - - - - - - - - -Round - - - - - - - - -Serum retinol:Age 0.810 0.000 0.626, 0.995 0.910 0.000 0.674, 1.145 0.641 0.000 0.353, 0.930Sex (m) -1.85 0.000 -2.87, -0.835 - - - -

3.3910.000 -5.04, -1.75

Group (f) 1.09 0.036 0.995, 1.01 - - - - - -Round - - - 1.305 0.001 0.545, 2.085 - - -Serum ferritinAge - - - - - - - - -Sex (m) - - - - - - - - -Group - - - - - - - - -Round 4.24 0.000 2.113, 6.37 3.97 0.009 0.936, 6.97 4.60 0.002 1.64, 7.57SerumtransferrinreceptorAge - - - -0.057 0.000 -0.089, -0.026 - - -Sex (m) - - - - - - - - -Group - - - - - - - - -Round - - - - - - - - -

1p<0.05 is taken as statistically significant

16

Discussion:

This double blind randomized trial of fortified wheat flour in which school agedchildren consumed two chapattis daily containing about 30 to 50% of the RDA formultiple micronutrients resulted in a significant improvement in vitamin A status ofthe children but no demonstrable improvement in anemia or iron status. Further, thestudy results indicated that the children found the chapattis made from fortified orunfortified flour highly acceptable as evidenced by the high chapatti consumption inboth groups.

Serum retinol concentrations were below recommended levels in a high proportion ofchildren in this age group at baseline, but these levels improved among those childrenreceiving fortified chapattis during the intervention. The levels in the control groupdid not improve. At 6 months, mean serum retinol level in the fortified group wassignificantly higher than the control group (p<0.01). Though an improvement hadbeen observed at 3 months in the control group compared to baseline level, serumretinol level at 6 months significantly decreased in this group compared to 3 monthslevel. The mid-point blood samples were collected during the time period from June30, 2002 to July 17, 2002 when â-carotene containing seasonal fruits available in themarket. The higher serum retinol levels in both the groups at 3 months might be dueto the consumption of â-carotene-rich mango and jackfruit by the children at thattime. The seasonal trends in dietary intake of vitamin A rich foods and lower trends ofmaternal and child night blindness during the months from June to August inBangladesh had been reported previously.17

There was a significant interaction between baseline serum retinol values and theresponse to treatment. The proportion of children with sub-clinical vitamin Adeficiency (<20 µg/dl) at baseline (13.6% vs.15.4%) significantly decreased at 3(7.9% vs. 16.2%) or 6 months (7.4% vs. 22.5%) in the fortified group. This trend wasalso observed in children of fortified group with sub-optimal vitamin A deficiency(serum retinol <30 µg/dl).

A high proportion of the children were anemic (37.6% and 45.8% of children in thefortified and control groups respectively) at baseline. At 6 months, there was nosignificant change in the proportion of anemic children in the two groups, nor in themean hemoglobin levels. We classified 19% and 24% of the total of the fortified andunfortified groups respectively as having iron deficiency at baseline based on lowferritin. This proportion did not change significantly within or between the groups at 6months.

Among those with low hemoglobin and low ferritin, there appeared to be a decreasein the proportion with this combination during the study, but there was no differencebetween the two treatment groups. Several factors may have contributed to lack ofimpact of fortification on iron and hemoglobin status of the children. The amount ofiron consumed by the intervention children was only 3.3 mg per day and this amountmay not be sufficient to correct anemia since their iron consumption from theirregular diet might be low. Moreover, the iron that was used in the fortified wheatmight not be as bioavailable as had been presumed. It was estimated that thebioavailability of the electrolytic iron, as was used in the fortificant, is 50% relative toferrous sulfate, but this may change depending on the particle size, or

17

hypochlorhydria, or other causes of iron malabsorption. If hookworm infestationscaused blood loss, these losses might be continuing during the treatment, making itless effective. Infection with H. pylori appears to be a common intestinal infection inBangladesh18 and other developing countries19, 20, 21 and can lead to hypochlorhydria.

The results of backward multiple regression analysis showed that over time serumretinol levels was increased significantly only in the fortified group.

Wheat is the second staple food of Bangladeshi population but is less commonlyconsumed compared to rice. Wheat production and consumption has increased overthe recent years. Wheat has the advantage of being more centrally processed than ricein Bangladesh and it is technically easier to fortify with micronutrients. The averageper capita consumption of wheat was only 20g in rural Bangladesh in 1998,17 far lessthan the amount of flour (100g) used in this intervention. Consumption data of thisstudy clearly demonstrated that children who participated in the study liked thechapattis. Moreover, a group of experts performed an organoleptic test of chapattimade from wheat flour based on hedonic scales of different parameters such as,colour, flavour, taste, mouth-feel, and overall satisfaction. The test had revealed thatchapatti made from fortified flour using hot water had a number of qualities with highacceptability.22 Therefore, wheat flour could be a suitable vehicle to be fortified withmicronutrients for targeted as well as general population of this country.

The findings of this study are consistent with those of previous community trials indeveloping countries where staple food products have been fortified with vitamin A.

Previous studies showed that fortification of condiments such as sugar,8 monosodiumglutamate,23 margarine,24 and wheat flour bun (pandesal)10 with vitamin Asubstantially improved vitamin A status. On the other hand, unlike this study,community trials conducted in developing countries with iron-fortified staple foods orcondiments showed statistically significant, but small, improvements in thehemoglobin and or iron status.25, 26, 27

This is the first study in Bangladesh that tested the efficacy of consuming chapattimade from wheat flour fortified with vitamin A, iron and other micronutrients. Thisstudy clearly has demonstrated a significant improvement in the vitamin A status ofthe school-age children in rural Bangladesh, but did not demonstrate an improvementin anemia or iron status.

18

Reference List

1. Underwood BA, Smitasiri S. Micronutrient malnutrition: policies and programsfor control and their implications. Annu.Rev.Nutr. 1999;19:303-24

2. Glasziou PP, Mackerras DE. Vitamin A supplementation in infectious diseases:a meta-analysis. BMJ 1993;306:366-70

3. Fawzi WW, Chalmers TC, Herrera MG, Mosteller F. Vitamin Asupplementation and child mortality. A meta-analysis. JAMA 1993;269:898-903

4. Keith West Jr. The magnitude of vitamin A deficiency disorders (VADD). 25years of progress in controlling vitamin A deficiency: Looking to the future, XXInternational Vitamin A Consultative Group (IVACG) Meeting held in Hanoi,Vietnam, 12-15 February 2001, Newsletter 1/2001, SIGHT AND LIFE

5. FAO- Nutrition Country Profiles: Bangladesh, March 25, 1999. FAO, Rome

6. World Bank. Investing in Health. World Development Report 1993. New York:Oxford University Press, 1993

7. Ian Darnton-Hill. Overview: Rationale and elements of a successful food-fortification programme. Food and Nutrition Bulletin, 1998; vol. 19(no. 2):92-100

8. Arroyave G, Mejia LA, Aguilar JR. The effect of vitamin A fortification ofsugar on the serum vitamin A levels of preschool Guatemalan children: alongitudinal evaluation. Am J Clin Nutr, 1981; 34:41-49

9. Layrisse M, Chaves JF, Mendez C, Bosch V, Tropper E, Bastardo B, GonzalezE. Early response to the effect of iron fortification in the Venezuelan population.Am.J.Clin.Nutr. 1996;64:903-07

10. Solon FS, Klemm RD, Sanchez L, Darnton-Hill I, Craft NE, Christian P, WestKP, Jr. Efficacy of a vitamin A-fortified wheat-flour bun on the vitamin A statusof Filipino schoolchildren. Am.J.Clin.Nutr. 2000;72:738-44

11. Report on Market Survey of Flour Mills of Bangladesh, WFP, Dhaka, July 31,2000

12. National Center for health Statistics. NCHS growth curves for children: birth –18 years. Washington, DC: USDHEW, 1977

13. Rice EW. Rapid determination of total hemoglobin as hemiglobin cyanide inblood containing carboxyhemoglobin. Clin.Chim.Acta 1967;18:89-91

14. Driskell WJ, Neese JW, Bryant CC, Bashor MM. Measurement of vitamin Aand vitamin E in human serum by high-performance liquid chromatography.J.Chromatogr. 1982;231:439-44

15. Bieri JG, Tolliver TJ, Catignani GL. Simultaneous determination of alpha-

19

tocopherol and retinol in plasma or red cells by high pressure liquidchromatography. Am.J.Clin.Nutr. 1979;32:2143-49

16. Furr HC, Tanumihardjo SA, Flores H, Olson JA et al. Assessment of humanvitamin A status using relative dose response (RDR) and modified relative doseresponse (MRDR) tests: manual, Dept of Biochemistry and Biophysics. ISU,Ames, USA, 1992

17. NSP Annual Report 1998. HKI and Institute of Public Health Nutrition, August1999

18. Sarkar SA, Mahalanabis D, Hildebrand P, Rahman MM, Bardhan PK, Fuchs G,Beglinger C, and Gyr K. Helicobacter pylori: Prevalence, transmission, and serumpepsinogen II concentrations in children of a poor periurban community inBangladesh. Clinical Infectious Diseases 1997;25:990-95

19. Gill HH, Desai HG, Majumdar P, Mehta PR, and Prabhu SR. Epidemiology ofHelicobacter pylori: the Indian scenario. Indian J Gastroenterol 1993 Jan;12(1):9-11

20. Misra V, Misra SP, Dwivedi M, and Singh PA. Point prevalence of peptic ulcerand gastric histology in healthy Indians with Helicobacter pylori infection. Am JClin Nutr 1997 Sep;92(9): 1487-91

21. Megraud F, Brassens-Rabbe MP, Denis F, Belbouri A, and Hoa DQ.Seroepidemiology of Campylobacter pylori infection in varios populations. J ClinMicrobiol 1989 aug;27(8) 1870-73

22. Malek MA and Bhuyan MAH. Report of Organoleptic Test of Fortified Atta.Institute of Nutrition and Food Science, Universtity of Dhaka, Dhaka-1000,Bangladesh 28 August, 2001

23. Muhilal, Murdiana A, Azis I, Saidan S, Jahari AB, Karyadi D. Vitamin A-fortifiedmonosodium glutamate and vitamin A status: a controlled field trial. Am J ClinNutr 1988; 48:1265-70

24. Solon FS, Solon MS, Mehansho H, et al. Evaluation of the effect of vitamin A-fortified margarine on the vitamin A status of preschool Filipino children. Eur JClin Nutr 1996; 50:720-23

25. Zimmermann MB, Zedre C, Chaouki N, Saad A, Torresani T, and Hurrel RF. Dualfortification of salt with iodine and microencapsulated iron: a randomized,double-blind, controlled trial in Moroccan schoolchildren. Am J Clin Nutr2003;77:425-32

26. Sari M, Bloem MW, Pee de S, Schultink WJ, and Sastroamidjojo S. Effect of iron-fortified candies on the iron status of children aged 4-6 y in East Jakarta,Indonesia. Am J Clin Nutr 2001;73:1034-39

20

27. Stuijvenberg ME Van, Kvalsvig JD, Faber M, Kruger M, Kenoyer DG, andBenade AJS. Effect of iron-, iodine-, and â-carotene-fortified biscuits on themicronutrient status of primary school children: a randomized controlled trial. AmJ Clin Nutr 1999;69:497-503

Appendix C

ACCEPTABILITY AND UTILISATION OF FORTIFIED ATTADISTRIBUTED UNDER THE PILOT PROJECT FOR

ATTA FORTIFICATION

PART I

Final

Acceptability and Utilisation of Fortified AttaDistributed Under the Pilot Project for

Atta Fortification

Prepared by:

AKM Ghulam HussainDepartment of Economics

Dhaka University

Mohammad Fariduddin KhanAsian Institute

Asian University of Bangladesh

December 2002

Submitted by

Asian InstituteAsian University of Bangladesh

1

Table of Contents

Page

Table of Contents 1

List of Tables 2

List of Figures 2

List of Acronyms 2

Executive summary 3

1. Introduction 6

1.1. The Study Background 6

1.2. Objectives of the present study

1.3. Methodology 7

1.3.1. Rapid Rural Appraisal 7

1.3.2. Questionnaire Survey 7

2. Study Findings 9

2.1. Socio-economic Status of the Respondents 9

2.1.1. Age, Marital Status, and Family Size 9

2.1.2. Education, Occupation, and Income Status 10

2.2. The Choice between fortified Atta and wheat 11

2.3. Taste and Quality of Fortified Atta 12

2.4. Level of Utilisation of Fortified Atta 15

2.5. Awareness: Knowledge About the Beneficial Impact of Fortified Atta 16

3. Concluding Remarks and Recommendations 21

Annexure 24

2

List of Tables

Table 2.3.1: Appearance of Fortified Atta 13Table 2.3.2: Storability of fortified atta 14Table 2.3.3: Comparison of project atta with respect to market atta 14Table 2.4.1: Level of utilisation of fortified atta

(per cent of VGD members) 15Table 2.4.2: Requirement vis-à-vis level of utilisation 16Table 2.5.1: Whether came across any NGO campaign on the fortified atta 17Table 2.5.2: Information received from BCC materials

explaining the benefits of fortified atta 17Table 2.5.3: Main source of information on fortified atta (per cent) 17Table 2.5.4: Understandability of the benefits of the micro-nutrients

added to atta 18Table 2.5.5: How many nutritional elements are there in fortified atta? 18Table 2.5.6: Number of nutritional benefits obtained from

consuming fortified atta 18Table 2.5.7: Intensity of preference: alternative to non-availability

of project atta for free 20

List of Figures

Figure 2.1.1: Distribution of Sample by Household Heads 9Figure 2.1.2: Maximum Level of Education Attained by Any

Member of the Household 10Figure 2.2.1: Respondents’ perception about whether the project

atta is more convenient 12Figure 2.3.1: Taste of fortified atta 13

List of Acronyms

LDCs Least Developed CountriesMOST Micro-nutrient Operational Strategies and TechnologiesWFP World Food ProgrammeVGD Vulnerable Group DevelopmentNGO Non-government OrganisationBNNC Bangladesh National Nutrition CouncilNPAN National Plan of Action on NutritionBCC Behavioural Change CommunicationMFU Milling and Fortification UnitRRA Rapid Rural AppraisalAtta Whole Wheat Flour

3

Executive Summary

A vast majority of population in Bangladesh suffer from chronic malnutrition

resulting from widespread micronutrient deficiencies in the food they consume. This

has prompted the Bangladesh National Plan of Action on Nutrition (NPAN) to

recommend fortification of certain foodstuffs in order to lessen the severity of the

malnutrition problem. Unfortunately however, the ground reality is something else:

there is hardly any food staple that is regularly fortified with micronutrients.

It is against this backdrop that MOST/USAID and WFP have involved themselves

with a Pilot Project for Atta Fortification. Under this project, wheat atta is fortified

with some selected micronutrients and then distributed among approximately 10,000

Vulnerable Group Development (VGD) households in three different districts of

Gaibandha, Kushtia, and Madaripur. The project is undertaken for an experimental

period of six months during which time each VGD member is entitled to 25 kg. of

fortified atta every month.

The basic objective of the present study is to evaluate whether the fortified atta

constitutes a familiar, convenient, more acceptable, nutritious and comparatively low-

cost food ration for the target population and to investigate whether it is used for the

purpose intended. Towards this end, about 1,000 households have been made

respondents for both rapid rural appraisals and detailed questionnaire survey

techniques.

On the whole, results show that while fortified atta constitutes not only an efficient

means of providing important livelihood support to the most vulnerable segment of

population, it also ensures a better nutritious diet for them.

The pilot project replaces the existing allocation of 30 kg whole-wheat grain per

member with 25 kg of fortified atta. Almost all respondents were of the view that the

latter program was more convenient than the former. This is because the allotment of

wheat can at best provide 27 kg of atta but the cost of milling is worth about another

4

2 kg of flour at market price. Moreover, most milling facilities are located at some

distance from the beneficiaries’ residence thus requiring additional resource and time

cost for processing and preparing them for eventual consumption.

Many beneficiaries also pointed out that prior to the pilot project they never actually

received 30 kg wheat, as the local influential persons used to misappropriate a

portion of the allotment during distribution. Since the project atta is distributed in

sealed bags, beneficiaries are now spared of any unwanted leakage.

About 90 percent of the respondents ( 97, 92 and 89 percent in Kushtia, Gaibandha

and Madaripur respectively) thought that the project atta looked different from

ordinary market atta, as the former was slightly coarser than the latter. However, 70

percent of all respondents thought that this did not affect the taste.

In terms of cleanliness and susceptibility to insect attacks, the overwhelming majority

of VGD members found the project atta to be superior to market atta. Only in terms of

coarseness, however, the project atta was deemed to be inferior to market atta,

implying that the project atta was coarser. The study further revealed that this was

deliberately kept thick in order to prevent it from being traded or sold by VGD

members. All existing mills have the capacity to produce fine texture atta and the

resultant cost increase will also be marginal. It was gathered that such refined atta

could be supplied at an addition cost of 2-3 per cent only.

The survey results also show that the level of consumption/utilisation of fortified atta

is quite high in all districts. The proportion of households that reported having

consumed more than 23 kg of atta was about 93 percent in Kushtia, 88 percent in

Gaibandha and 92 percent in Madaripur. For a few households, the level of

consumption was found to be quite low. This was because some households tried to

refine the project atta by sifting out the coarser materials in their traditional ways

and in the process, the quantity of actual atta available for consumption was,

therefore, considerably reduced.

A small percentage of respondents (i.e., about 7, 24, and 15 percent respectively in

Kushtia, Gaibandha and Madaripur) reported having sold some quantity of the

5

project atta. The principal reason cited for this being the inability to meet other needs

of the households. Furthermore, it was observed that when the household’s overall

requirement (for atta) had been less than 25 kg, the distributed atta was rarely fully

utilised. However, when the need was more than the amount allotted, full utilisation

was the norm in more than 80 percent of households in all areas.

With regard to the awareness building aspect of the atta-fortification program, the

study findings reveal that most households have reportedly heard some NGO

initiatives or have seen posters explaining the benefits of fortified atta. However, the

questionnaire survey reveal that user information on and perception of the

beneficiaries about the micronutrients added to the atta seems to be low. This seems

to suggest that a more aggressive campaign about the benefits of fortified atta be

launched for the success of the project.

Regarding the question as to whether the households will continue using the fortified

atta if it is not given free, about one-third of the households responded in the

affirmative, while about 45 percent of them said they would switch to rice. While one

may tend to interpret this response as a pointer to a poor performance of the project,

this paper argues that given the traditional eating habits and general perception

about the superiority of rice to wheat among Bangladeshis, and the information gap

about the benefits of the fortified atta, such a response comes as no surprise. The

study therefore argues that, had the awareness campaign been more intensively

pursued, the project could have motivated more people to use the fortified atta even it

were not given free.

On the whole, the study finds the atta fortification project to be an effective way of

supporting the poor people with micronutrient-rich foodstuffs. The distribution of atta

is found to be more convenient to the beneficiaries. Moreover, the high utilisation rate

also indicates the acceptability by the VGD members. However, there exists some

scope for a strengthened awareness campaign programme, which can motivate the

beneficiaries about the real benefits of fortified atta. Finally, the study suggests that

technically feasible ways should be explored to minimise the perceived physical

differences in attributes between the project atta and the non-fortified marketed atta

so that former could secure a more general acceptance among the beneficiaries.

6

1. Introduction

1.1. The Study Background

Improved nutritional status has long been acknowledged as a major component of any efforts

to ensure basic needs of poor and vulnerable economic groups. In the long run, it not only

helps achieve productivity growth (so that production and consumption of goods and services

can be expanded), but also ensures a more equitable distribution of consumption goods

among the members of the society. 1

Like many other least developed countries (LDCs), Bangladesh suffers from malnutrition

which is endemic. The worst sufferers are, understandably, women and children in

economically poor households. Their micronutrient deficiencies have assumed a chronic

proportion. Unfortunately, however, there is hardly any food staple that is regularly fortified

with micronutrients despite the fact that such schemes can have significant positive impact on

the health and nutritional condition of the population in the country. 2

It is against this backdrop that MOST/USAID and WFP have involved themselves with a

Pilot Project for Atta Fortification. Under this project, wheat atta is fortified with some

selected micronutrients and then distributed among approximately 10,000 Vulnerable Group

Development (VGD) households in three different districts of Gaibandha, Kushtia, and

Madaripur. The project is undertaken for an experimental period of six months during which

time each VGD member is entitled to 25 kg. of fortified atta every month.

1.2. Objectives of the present study

The present study seeks to investigate the level of acceptability and utilisation of the fortified

atta under the pilot project. It examines how the target population has accepted fortified atta

and how their attitudes have developed towards fortification. The study also takes a look at

the impact of the shift from whole grain wheat to fortified atta and offers a comparative

analysis of the benefits accruing to members vis-à-vis the previous system of whole grain

wheat. Particular emphasis will also be given to ascertain the utilisation of the fortified atta

1 For detailed discussion see Behrman, J. (1993) “The Economic Rationale for Investing in Nutrition inDeveloping Countries, World Development, vol.21, no.11, pp.1749-1771.2 The Bangladesh National Plan of Action on Nutrition (NPAN) also recommends that a strategy forthe fortification of certain foodstuffs be adopted in order to lessen the severity of malnutrition problem.

7

by the beneficiaries by determining the leakages and wastages that might arise from the

programme.

The pilot project is not merely about distributing foods among the vulnerable people; it is also

about providing quality foods and about making people motivated to utilise the distributed

fortified atta at a maximum possible level. Therefore, another important aspect of the present

study will be to assess the level of motivation of the target population to use the food, which

is rich in micronutrients essential for maintaining a healthy living. The study makes an

attempt to gauge the propensity of the beneficiaries to substitute the fortified atta for other

principal food items in general, and for the main staple food rice, in particular. The

knowledge about the intensity of preference of the consumers is important for ascertaining the

long-term viability of the atta fortification. Moreover, the motivational aspect of for using the

fortified food can further be evaluated from such preference pattern. Addressing these key

issues and questions would provide the study with critical insights for evaluating whether the

fortified atta constitutes a familiar, convenient, acceptable, nutritious and comparatively low-

cost intervention programmes for the target population.

1.3. Methodology of the study

1.3.1. Rapid Rural Appraisal

Given the nature of the pilot project and the intended objectives outlined above, it was

necessary to gather the information through primary survey. In this regard, two standard

techniques were used. Rapid Rural Appraisal (RRA) technique was used to make a qualitative

assessment of the behaviour of the target population,. This involved direct observation and

focussed group discussions with the programme participants, organisers and other

stakeholders. A pre-designed checklist was used for guiding the RRA and field investigators

were asked to keep detailed notes of the discussions.

1.3.2. Questionnaire Survey

Apart from the RRA, formal and structured interview surveys were carried out in each of the

districts where the pilot project was being implemented. The VGD households covered by the

atta fortification project (a total of 9870) were spread across 151 unions and more than 1000

villages. Three Upazillas – one from each district – were chosen out of which 13 Unions and

more than 100 villages were covered for in-depth questionnaire survey of about 1000

8

households.3 Since the VGD members under the project were thinly scattered across around

1000 villages, to keep the number of villages within a manageable limit, every available

member of the selected villages were interviewed. Eliminating the questionnaires that

contained missing observations, the size of the sample for analysis stood at 988.

3 The target was to interview 325-350 households from each Thana/Upazilla.

9

2. Study Findings

2.1. Socio-Economic status of the respondents

2.1.1. Age, Marital Status and Family Size

Tables in the annexure provide some basic information on age, martial status and family size

of the respondents. For the whole sample, almost 50 per cent of the members fall within the

age bracket of 31-45 years.4 The next most important age group is 19-30 years comprising

about respectively 31, 26 and 34 per cent sample in Kushtia, Gaibandha and Madaripur

districts. Whilst as low as 3 per cent of the respondents are aged over 60, quite a few members

are actually young (aged less than 19 years).

During the RRA, field investigators observed that many of the youngest members actually do

not fall within the definition of target population. The VGD programmes support a large

number of most vulnerable women. Widowers comprise between 21 and 39 per cent of the

members. After excluding the members who never got married, it is estimated that about 35

per cent (or a total of 343 women) of the respondents were living without the support of their

husbands. Indeed, our survey reveals that the proportion of the female-headed households in

the sample is quite high in every district: 32, 39 and 37 per cent respectively in Kushtia,

Gaibandha, and Madaripur (see Figure 2.1.1).

Figure 2.1.1: Distribution of Sample by Household Heads

Household head

0

10

20

30

40

50

60

70

80

Kushtia Gaibandha Madaripur

Per

cen

t

Male Female

4 Most members aged between 31-45 are from Kushtia representing about 53 per cent of the sample forthe district.

10

Most VGD members have family size less than 5 in Kushtia and Gaibandha. But in

Madaripur average family size is found to be unusually large. For example, while in Kushtia

and Gaibandha about 12 per cent of households have average family size above 6, the

comparable figure for Madaripur is 30 per cent. It is not clear why the incidence of large

family is so high in Madaripur.5

2.1.2. Education, Occupation and Income Status

The maximum level of education attained by any person in the sample members’ households

is shown in Figure 2.1.2. All members in more than half of the surveyed households in

Gaibandha were reported to be illiterate. For Kushtia and Madaripur, the comparable figure is

somewhat lower, at about 37 per cent. Only a few households have a member with education

above SSC.

Figure 2.1.2: Maximum Level of Education Attained by Any Member of the Household

0

10

20

30

40

50

60


per

cent

Illiterate IV-V VI-VIII IX-X SSC and above

More than 70 per cent of the respondents covered in the sample were not engaged with in any

kind of income generating activities (housewives). For married members most husbands were

working as day labourers in Kushtia and as small farmers in Gaibandha and Madaripur.

5 Traditional practices and cultural values with regard to coping strategies during economic crises andnatural disaster might be the reasons for large family size. However, the problem related to smallsample bias cannot be ruled out altogether.

11

Monthly income of the members’ households is catalogued in the Appendix. It is observed

that majority of households have monthly income upto Tk. 2000. About 80 per cent of sample

respondents in Gaibandha have family income of less than Tk. 1000 although for Kushtia and

Madaripur such figures correspond to 35 and 18 per cent respectively. 6 Coupled with low

income, 93 per cent households in Gaibandha has also the lowest amount of landholding

followed by their counterparts in Kushtia (80 per cent) and Madaripur (69 per cent).

2.2. The choice between fortified atta and wheat

As mentioned earlier, the pilot project has replaced the whole grain wheat with fortified atta.

When wheat is distributed it adds some additional costs to the VGD members both in terms of

time and financial resources, as the distributed wheat has to be washed and dried before

grinding into flour. Most often milling facilities do not exist in the vicinity of members’ living

place making it necessary for them to transport the wheat to the nearest town centre. Many

beneficiaries prefer not to carry and crush the whole allotment at a time, which further

accentuates their problem. Considering all this, the introduction of atta may be regarded as a

welcome move. During the field survey an attempt was made to know whether the VGD

members perceived receiving such benefits from the pilot project.

RRA and the questionnaire survey reveal that the allotment of 30 kg wheat can at best provide

27 kg of atta.7 The cost of milling is between Tk. 0.75-1.0 per kg of wheat, i.e., at least

Tk.22.5 on the whole allotment of 30 Kg, which is worth of just about 2 kg of flour at the

market price. Therefore, consideration of milling cost alone reduces the effective allotment to

25 kg of atta. If the costs of transportation and the time required for processing the wheat

before milling are considered the effective entitlement out of wheat will be reduced further.

In the above context, the allocation of 25 kg of fortified atta per VGD member is to be

considered as more convenient, which is overwhelmingly supported by the results of

questionnaire survey; 99.7, 93.6 and 98.5 per cent respondents respectively in Kushtia,

Gaibandha and Madaripur opined that compared with whole wheat the fortified atta was more

6 Note that the monthly income of the household may not be a good indicators of economic well-beingbecause the size of the household is not being considered.7 During milling about 2-2.5 kg of wheat residue is generated, which can only be used as poultry orcattle feed. The market price of wheat residue is negligible and since most beneficiaries do not crushthe whole allotment at a time they usually cannot sell such small amount. Most cases the mill ownerkeeps the residue offering a very negligible discount on the milling bill.

12

convenient to them (see Figure 2.2.1). In-depth discussions with the VGD members during

RRA revealed that before the introduction of the pilot project, households on an average spent

3-5 days on the preparation of wheat flour. Therefore, when asked why the project atta was

more convenient, about 60 per cent respondents in all 3 districts mentioned its time-saving

convenience. According to another 35 per cent of the sample respondents, the effective

quantity of project atta is actually higher than that of wheat grains. In the focus group

discussions, many beneficiaries informed that prior to the pilot project, they never received

full 30 kg wheat as the local influential persons used to misappropriate a portion of the

allotment during distribution. Since the project atta is distributed in sealed bags, VGD

cardholders now do not suffer from any unwanted leakages.

Figure 2.2.1: Respondents’ perception about whether the project atta is more convenient

0%

20%

40%

60%

80%

100%

per

cent

of

resp

onde

nts


More Convenient Less Convenient

Therefore, even without considering the benefits that fortified atta accrue to the beneficiaries

(in terms of added micro-nutrients), they regard the project atta to be much more convenient

than the whole-wheat grain. The pilot project thus saves the beneficiaries time needed to

prepare and transport the wheat for milling, and cost of transportation and milling and other

unwanted leakages.

2.3. Taste and quality of fortified atta

Taste and quality are most important issues in considering a food item consumed regularly.

Consequently, it is important to know how adequately the fortified atta meets the taste and

quality consciousness of the beneficiaries. There is no denying that project atta looks slightly

different from the ordinary atta as found in the market; the former is a little coarser than the

13

latter. Table 2.3.1 shows that most members can distinctly identify the project atta quite easily

since about 97, 92 and 89 per cent sample respondents respectively in Kushtia, Gaibandha,

and Madaripur report “project atta looks different”. The reason for difference in appearance

was also mostly attributed to coarseness of the project atta.

Table 2.3.1: Appearance of Fortified Atta

Area Project atta looks different(per cent of respondents)

Does not look different(per cent of respondents)

Kushtia 97.4 2.6Gaibandha 92.3 7.7Madaripur 89.0 11.0

Does the difference in appearance have any bearing on the taste? Our survey results show that

most beneficiaries are positively inclined about the taste of the project atta. Taste is reported

to be good in all areas, particularly in Kushtia, where it is highly satisfactory (see Figure

2.3.1).8 There has been some complaints about the bad and bitter taste of the fortified atta in

Gaibandha and Madaripur; just above 20 per cent sample beneficiaries reported that either the

taste is bad or bitter.

Figure 2.3.1: Taste of fortified atta

0

1020

3040506070

8090

100

per

cent

of

resp

onde

nts


Tastes good Does not taste good

8 97 per cent of sample beneficiaries in Kushtia were of the view that project atta tastes good.

14

The storability of any staple food is extremely important and in this respect the performance

of fortified atta is very impressive. Nearly all VGD households in Kushtia were satisfied with

the storability of the project atta. In Gaibandha and Madaripur the corresponding figures were

94.2 and 92.3 per cent respectively. Though a small proportion of households in each area

have reported that fortified atta gets spoiled regularly, the incidence of such reporting is

highest in Madaripur (see Table 2.3.2).

Table 2.3.2: Storability of fortified atta

Area Storability is satisfactory(per cent)

Goes bad regularly(per cent)


Table 2.3.3: Comparison of project atta with respect to market atta

DirtyAreaMore Similar Less

Kushtia 1.5 0.6 97.9Gaibandha 20.7 10.0 69.3Madaripur 18.5 12.0 70.0

Susceptible to insect attacksMore Similar Less

Kushtia 0.6 0.3 99.1Gaibandha 15.0 20.0 65.0Madaripur 12.1 - 87.9

CoarseMore Similar Less


TasteBetter Similar Worse


Finally, Table 2.3.3 makes some comparison between project atta and market atta based on

the evaluation by the beneficiaries themselves. Nearly all respondents in Kushtia thought that

the project atta was less dirty than market atta. Although the proportion of beneficiaries with

such a perception is lower in Gaibandha and Madaripur, nevertheless around 70 per cent of

the respondents supported the view expressed by most people in Kushtia. Similarly, the

majority of people in all districts reported that project atta was less susceptible to insect

15

attacks. One negative aspect of the project atta is its coarseness, as more than 90 per cent

respondents find project atta to be more coarse than the ordinary atta. Despite its coarseness,

about two-thirds to four-fifths VGD members thought that fortified atta tasted the same as

market atta to.

2.4. Level of utilisation of fortified atta

What do the beneficiaries do with fortified atta? Do they consume the whole lot or use a

portion for trading? Our survey shows that the level of consumption/utilisation of fortified

atta is quite high in all sample areas. The percentage of households that reported to have

consumed more than 23 Kg of atta was about 93 per cent in Kushtia, 88 per cent in Gaibandha

and 92 per cent in Madaripur. In Gaibandha about 10 per cent households consumed only 16-

20 kgs and the corresponding figures for Kushtia and Madaripur were 4.4 and 6 per cent

respectively (Table 2.4.1).

Table 2.4.1: Level of utilisation of fortified atta (per cent of VGD members)

Area Less than 10 kg 11-15 kg 16-20 kg 21-22 kg 23-25 kgKushtia - - 4.4 2.9 92.7Gaibandha - 0.6 9.3 2.3 87.8Madaripur 0.3 - 6.0 1.5 92.3

The low utilisation by some households (although constituting a negligible proportion in the

sample) could be explained by two factors: coarseness of the fortified atta and the low level of

awareness on the part of the beneficiaries. Lack of awareness, as we will see later,

discourages VGD members from possible maximum utilisation of the distributed atta.

About 7, 24 and 15 per cent of respondents respectively in Kushtia, Gaibandha and Madaripur

reported to have sold some quantity of the project atta. Meeting other expenses (such as health

expenses) was the most significant reason for most households to sell out the fortified atta. In

Kushtia and Gaibandha, some beneficiaries, opting for more variety in their diet, sold some

atta to be able to buy other processed foods. Besides, the requirement was low for some VGD

members, which encouraged them to sell the excessive quantity.

In contrast, the VGD members who have not sold the fortified atta indicated that the primary

reason for not doing so is high family requirement. The percentage of households that have

16

indicated high requirement as primary reason for not trading were 79.4 per cent in Kushtia,

75.1 per cent in Gaibandha, and 89.1 per cent in Madaripur. Table 2.4.2 provides information

on the level of utilisation of fortified atta vis-à-vis the requirements of the households. It is

found that when the requirement is less than 25 kg, full utilisation is negligible in all districts.

However, when the need was more than the amount allotted, full utilisation was the norm in

more than 80 percent of households in all areas.

Table 2.4.2: Requirement vis-à-vis level of utilisation

Area Need of the households Full utilisation by per cent of householdsKushtia Less than 25 kg 0.9

25 kg 72.5More than 25 85.0

Gaibandha Less than 25 kg 1.625 kg 70.0

More than 25 90.0Madaripur Less than 25 kg 0.6

25 kg 75.0More than 25 82.1

2.5. Awareness: knowledge about the beneficial impacts of fortifiedatta

The fortified atta project is associated with building awareness among the target population

about the nutritional contents in the foodstuffs that they consume. Briefings by the NGO

workers and BCC materials explaining the benefits of fortified atta have been the two most

important instruments in this regard. In each area more than 92 per cent of sample

respondents reported to have heard about the initiatives taken by the NGO workers. Only a

few households were found to be uninformed, and within that group the largest percentage

was observed in Gaibandha (see Table 2.5.1). Similarly a vast majority of members, as shown

in Table 2.5.2, has also seen posters displaying the merits of fortified atta consumption.

Households that have not noticed the posters constituted 8.8 per cent in Kushtia, 12.5 per cent

in Gaibandha and 3.9 per cent in Madaripur. Although the figures are not very high, it is

expected that NGO outreach service should be made available to all VGD members.

Particularly, in Gaibandha a good proportion of household has remained out of reach.

17

Table 2.5.1: Whether came across any NGO campaign on the fortified atta

Area Heard about the NGOinitiative

Didn’t hear anything


Table 2.5.2: Information received from BCC materials explaining the benefits offortified atta

Area Have seen posters Haven’t seen any posterKushtia 91.2 8.8Gaibandha 87.5 12.5Madaripur 96.1 3.9

The VGD households were asked about their primary source of information regarding the

benefits of fortified atta. In Kushtia, as Table 2.5.3 shows, most households (85 per cent)

reported to have obtained information mainly from distributional meetings followed by NGO

campaign (12.6 per cent). Whilst in Gaibandha, all possible sources were almost equally

distributed over the households; largest percentage of respondents in Madaripur acquired the

basic information from posters followed by NGO campaigning (25 per cent).

Table 2.5.3: Main source of information on fortified atta (per cent)

Area Distributionalbriefings

NGO campaign Posters Others

Kushtia 85.0 12.6 0.6 1.8Gaibandha 29.3 34.7 31.2 4.8Madaripur 5.4 25.0 66.4 3.3

The distributional briefings, campaign by the NGOs and posters constitute the main vehicles

for raising the awareness of the target population and thereby motivating them to utilise the

fortified atta. Of course, it is essential that beneficiaries correctly perceive and understand the

benefits of micronutrients added to the project atta. Unfortunately, this aspect has been an

important missing link. Only in Kushtia a substantial amount of respondents (about 82 per

cent) was convinced that they understood what was meant by the campaign. For Gaibandha

and Madaripur much lower percentage of households achieved such understanding. The

percentage of members that cannot understand the information on micronutrients is highest in

Madaripur (43.5 per cent) followed by Gaibandha (33.8 per cent).

18

Table 2.5.4: Understandability of the benefits of the micro-nutrients added to atta

Area Understand Don’t understand Can’t rememberKushtia 81.8 1.5 16.7Gaibandha 56.9 9.3 33.8Madaripur 55.4 1.2 43.5

Through the questionnaire survey other attempts were made to evaluate the level of awareness

among the beneficiaries. The members were asked to mention the name of the nutritional

elements in the fortified atta. On this, a large percentage of members in all the study areas

could not state a single element (see Table 2.5.5). In Gaibandha about 44 per cent of members

were able to report just one nutrient, which is the largest percentage of members that could

mention any. The largest number of members that could mention 4-6 elements was observed

in Kushtia.

Table 2.5.5: How many nutritional elements are there in fortified atta?

Area None Only 1 2 3 4-6Kushtia 43.4 29.6 19.9 4.4 2.6Gaibandha 54.7 43.7 1.3 0.3 -Madaripur 51.5 22.9 20.5 4.2 0.9

Apart from the names of the micronutrients, the members were asked to specify the benefits

associated with consumption of the fortified atta. A successful awareness campaign would

reflect the ability of the beneficiaries to correctly reveal the benefits perceived by them.

However, the results of our survey seem to be quite disappointing, as significant proportions

of people could not mention any of the nutritional benefits. Particularly in Gaibandha more

than half of the respondents were totally ignorant about the beneficial impact of fortified atta

(see Table 2.5.6).

Table 2.5.6: Number of nutritional benefits obtained from consuming fortified atta

Area None Only 1 2 3 4-6Kushtia 29.3 17.9 37.8 13.2 1.8Gaibandha 55.0 19.3 21.9 2.9 1.0Madaripur 44.3 15.2 25.0 11.6 3.9

19

An important aspect related to awareness is the intensity of preference shown in favour of the

project atta. The fortified atta is coarser than the ordinary atta even though it tastes similar but

does not look same as the latter.

On the other hand, the project atta is rich in micronutrients providing many unquantifiable

health benefits. Now, if people are well aware of the benefits, they may develop a strong

preference for fortified atta. Has this occurred to the case of project atta? The information

provided in Table 2.5.7 shows that between 26 and 30 per cent beneficiaries in all three

districts wished to continue the consumption of fortified atta even if it is not distributed

freely. While this may interpreted as a pointer towards a poor achievement of the project

objective, consideration of the eating habits of the poor households in Bangladesh can

actually give a different impression. This is because although rice and atta are the most

important staples in the diet of Bangladeshis, rice is usually considered much superior to

wheat or atta. Low-income households are found to spend about 60 per cent of their food

budget on rice compared to a meagre 4 per cent on wheat.9 Besides, wheat is often considered

as an inferior food and, therefore, the preference bias against wheat/atta and in favour of rice

is in-built into the eating habits.10

Besides, the difference between the market price of a kilogram of ordinary atta and the most

common coarser variety of rice is very small, which also encourages the substitution in favour

of rice. Consequently, it would be totally inappropriate to conclude that the project has been

unsuccessful in terms of generating a strong preference pattern in favour of fortified atta. As a

matter of fact, given the low level of understandability of the benefits of the project atta on the

part of the beneficiaries, the proportion of people showing strong preference for the project

atta, as reported in Table 2.5.7, should be considered very impressive. Nevertheless, had the

awareness building activities been successful, the project could have motivated many more

people for using the fortified atta permanently.

9 These estimates are from Razzaque, A., Khondker, B.H., and Mujerie, M.K. (1997), “ElasticityEstimates by Occupational Groups in Bangladesh: An Application of Food Characteristics DemandSystem”, Bangladesh Development Studies, vol.25, no. 3&4, pp.1-41. Rice, wheat, fish, pulses, beefand vegetables are principal items on which most of the food budget is spent.10 In fact, even in the sense of economics wheat is shown to be a inferior good in Bangladesh. Moststudies in Bangladesh have computed a negative income elasticity of demand for wheat (e.g., seeRazzaque et al. as above).

20

Table 2.5.7: Intensity of preference: alternative to non-availability of project atta forfree

Area Fortified atta Ordinary market atta Indifferent Rice Don’t know

Kushtia 30.3 8.0 20.5 41.4 0.3Gaibandha 25.9 18.0 1.0 55.0 1.6Madaripur 28.5 11.5 10.0 45.5 4.5

21

3. Concluding Observations and Recommendations

The study finds that fortified atta constitutes a familiar, convenient, acceptable, nutritious, and

comparatively low-cost food ration for the target population with lower unintended use. It

constitutes not only an efficient means of providing important livelihood support to the most

vulnerable segment of population, but also ensures a better nutritious diet for them.

In what follows, and in line with the findings of the study, some recommendations are made

with respect to a more effective implementation and wider programme coverage for eventual

replication across the country in future.

1. The socio-economic profiles of VGD members indicate that in many cases the criteria of

allocating VGD cards were not followed. The incidence of such cases is quite high, implying

that the fortified atta project has been directed towards the non-targeted population instead of

the genuine people who should be brought under the scheme. During the discussion meetings

with the VGD members as well as NGO workers, it became clear that VGD cards were

distributed by the administrative authorities on considerations other than those set for the

targeting criteria. The study therefore recommends that:

a more close supervision of the process of distribution of VGD cards on pre-set criteria be

initiated and implemented.

2. One of the programme components involved providing information to members to make

them aware of the benefits of fortified atta so that they become motivated into accepting and

consuming atta. A measure of success in this effort will be reflected in a greater utilisation of

fortified atta. However, the level of awareness among the beneficiaries in the study area has

been found to be quite poor and unsatisfactory. Recipients have, at the most, some superficial

understanding that fortified atta is beneficial for health although, in most cases, they could not

spell out the possible real effects. This lower level of awareness of VGD members can be

linked to poor performance of Behaviour Change Communication (BCC) programmes. The

planned BCC programmes may not have reached the beneficiaries, which is crucial for the

success of the programme. Another reason for low awareness might be attributable to the fact

that members, who are not economically vulnerable enough to qualify for VGD cards but

somehow managed to enter the programme, do not feel the necessity to attend the monthly

review and briefings. Consequently, they have little or no information/knowledge about the

benefits of fortified atta.

22

In order to enhance the level of utilisation (i.e. consumption) of fortified atta by VGD

members it is essential to strengthen the BCC campaign. The study therefore recommends

that:

The BCC campaign should be made more appealing to the members who should be

encouraged to attend participatory workshops and discussion programmes organized in this

regard.

3. BCC interventions were undertaken to build awareness about the beneficial effects of

fortified atta to a level such that the awareness effect in favour of fortified atta offsets the

habitual bias against atta. But the actual situation reveals that BCC programme was not

successful in achieving its goal.

4. The fortified atta programme is designed to ensure equality rather than equity. Currently 25

Kg of fortified atta is distributed to each VGD members irrespective of their need and socio-

economic status despite the fact that the level of poverty and vulnerability across members

vary considerably. Moreover, the need for fortified atta is also uneven due to differences in

family size of members’ households. However, the study acknowledges that considerations of

equity will generate complicated administrative procedures in determining the need of

individual members. This might also provide incentives for unscrupulous practices that would

undermine the objective of the project. The study therefore recommends that:

as a practical alternative, the NGOs be involved in determining the needs of the members.

A minimum and a maximum amount may be specified and the actual allotment to each

member then should fall within this range.

5. One of the common complaints of many beneficiaries is the coarseness of project atta,

which makes it distinguishable from the ordinary chakki milled atta. VGD members’

represent the poorest of the poor (with the exception of a few targeting error), who are known

to be less motivated, with low awareness and who often are socially excluded. 11 As a result,

when something, which is different from the products found in the market, is offered to them,

they erroneously perceive it to be of “low-quality” item.

Our investigation reveals that the existing milling system is capable of dealing with the

problem of coarseness of fortified atta. Indeed, it was learnt that the atta was made coarse

deliberately since it was apprehended that fine quality atta may bias the distribution system or

11 This based on the findings of Rahman, A. and Razzaque, A. (2000), “On Reaching the HardcorePoor: Some Evidence of Social Exclusion in NGO Programmes”, Bangladesh Development Studies,

23

could be traded or sold rather than consumed by the VGD beneficiaries. But investigation of

the actual situation indicates that due to coarseness many beneficiaries sift (filter) the atta to

make it finer.

Again, since the existing mills can produce finer quality atta as comparable to the local

market atta, and the additional cost for doing so will be marginal (the study estimates that the

cost will increase by only 2 to 3 per cent), and considering the wastage involved in

households sifting out by the traditional method, the study therefore recommends that:

the current system needs to be supplemented with provision for milling fortified atta and

making them available for use by the targeted beneficiaries.

6. Despite its importance, very little has been done to launch a nationwide campaign for

consumption of fortified atta. Most people outside the target population are not aware of the

benefits of atta fortification and consequently an effective demand for the fortification

programme is not adequately generated. For a commercially viable fortified atta programme,

the study therefore recommends that:

the awareness building efforts be more intensively pursued through media campaign for

motivating larger number of people into using fortified atta.

vol.26, no.1, pp.1-35. The study shows that a large proportion of this vulnerable group is also notreached by various social programmes of the NGOs.

24

AnnexureTable A-1: Age of VGD members

Age of VGD member Kushtia Gaibandha Madaripur Total

<19 0.59 0.64 3.27 1.52

19-30 31.09 26.37 33.63 30.47

31-45 52.79 48.23 46.73 49.29

46-60 13.78 21.22 13.39 15.99

>60 1.76 3.54 2.98 2.73

N 341 311 336 988

Table A -2: Marital Status of VGD members

Marital Status Kushtia Gaibandha Madaripur Total

Married 69.50 51.45 66.96 62.96

Unmarried 1.17 1.29 4.46 2.33

Divorced 1.47 2.25 0.30 1.32

Widow 21.41 39.23 26.79 28.85

Separate 6.16 4.82 1.19 4.05

Others 0.29 0.96 0.30 0.51

N 341 311 336 988

25

Table A -3: Family Size of VGD Households

Family Size Kushtia Gaibandha Madaripur Total

<5 49.85 56.91 26.19 44.03

5-6 37.83 30.55 43.15 37.35

7-8 9.68 9.00 23.21 14.07

>8 2.64 3.54 7.44 4.55

N 341 311 336 988

Table A -4: Education of the VGD members

Education Kushtia Gaibandha Madaripur Total

Completely Illiterate 128 37.54 178 57.23 125 37.20 431 43.62

Passed class 4-5 73 21.41 69 22.19 83 24.70 225 22.77

Passed class 6-8 82 24.05 32 10.29 71 21.13 185 18.72

Passed class 9-10 45 13.20 21 6.75 49 14.58 115 11.64

SSC and above 13 3.81 11 3.54 8 2.38 32 3.24

Total 341 100.00 311 100.00 336 100.00 988 100.00

Table A -5: Distance to Market

Distance to Market Kushtia Gaibandha Madaripur Total

<2.00 307 90.03 104 33.44 299 88.99 710 71.86

2.01-3.00 21 6.16 56 18.01 24 7.14 101 10.22

3.01-4.00 8 2.35 40 12.86 5 1.49 53 5.36

4.01-5.00 5 1.47 59 18.97 7 2.08 71 7.19

>5.00 0 - 52 16.72 1 0.30 53 5.36

Total 341 100.00 311 100.00 336 100.00 988 100.00

26

Table A -6: Land holding of the VGD Households

Land Kushtia Gaibandha Madaripur Total

<16 272 79.77 288 92.60 231 68.75 791 80.06

16-30 41 12.02 12 3.86 48 14.29 101 10.22

31-75 20 5.87 9 2.89 41 12.20 70 7.09

76-100 5 1.47 2 0.64 10 2.98 17 1.72

>100 3 0.88 0 - 6 1.79 9 0.91

Total 341 100.00 311 100.00 336 100.00 988 100.00

Table A -7: Occupation of VGD member’s Husband

Occupation of Husband Kushtia Gaibandha Madaripur Total

Service 8 3.76 4 2.48 7 3.03 19 3.14

Farmer 10 4.69 59 36.65 69 29.87 138 22.81

Business 35 16.43 19 11.80 24 10.39 78 12.89

Rickshaw 21 9.86 8 4.97 31 13.42 60 9.92

Day Labor 84 39.44 18 11.18 7 3.03 109 18.02

Unemployed 6 2.82 15 9.32 15 6.49 36 5.95

Fisherman 4 1.88 4 2.48 8 3.46 16 2.64

Others 45 21.13 34 21.12 70 30.30 149 24.63

Total 213 100.00 161 100.00 231 100.00 605 100.00

27

Table A -8: Occupation of the VGD members

Member Occupation Kushtia Gaibandha Madaripur Total

Housewife 242 72.02 224 72.26 240 71.64 706 71.97

Weaver 50 14.88 0 - 0 - 50 5.10

Factory Worker 1 0.30 1 0.32 7 2.09 9 0.92

Day Labor 4 1.19 29 9.35 8 2.39 41 4.18

Small Business 3 0.89 6 1.94 3 0.90 12 1.22

Beggar 0 - 2 0.65 6 1.79 8 0.82

Others 36 10.71 48 15.48 71 21.19 155 15.80

Total 336 100.00 310 100.00 335 100.00 981 100.00

Table A -9: Monthly Income

Income Kushtia Gaibandha Madaripur Total

<1000 119 34.90 247 79.42 60 17.86 426 43.12

1001-1500 96 28.15 46 14.79 91 27.08 233 23.58

1501-2000 70 20.53 11 3.54 81 24.11 162 16.40

2001-2500 23 6.74 6 1.93 44 13.10 73 7.39

>2500 33 9.68 1 0.32 60 17.86 94 9.51

Total 341 100.00 311 100.00 336 100.00 988 100.00

Table A -10: Gender of the Household Head

Household Head Kushtia Gaibandha Madaripur Total

Male 232 68.04 189 60.77 213 63.39 634 64.17

Female 109 31.96 122 39.23 123 36.61 354 35.83

Total 341 100.00 311 100.00 336 100.00 988 100.00

Appendix D

ACCEPTABILITY AND UTILISATION OF FORTIFIED ATTADISTRIBUTED UNDER THE PILOT PROJECT FOR

ATTA FORTIFICATION

PART II

1

Acceptability and Utilization of Fortified Atta:

A supplementary report on the acceptability of Fortified Roller Mill Atta

compared with currently distributed Fortified Hammer Mill Atta.

The present study is to supplement the previous study on Acceptability and Utilization of Fortified Atta.

The basic objective of this study is to evaluate whether the fortified roller mill atta is more acceptable than

fortified hammer mill atta currently distributed among the VGD members. To meet the objective both rapid

rural appraisal and detailed questionnaire survey techniques were used. This small survey was conducted

among three types of households- discontinued VGD members in the current cycle, current members and

non-members target group. Five villages under Kumerkhali Upazilla in Kustia district were covered. Since

fortified roller mill atta is not available for distribution among the VGD members, we arranged 100kg roller

mill atta and 100kg hammer mill atta duly fortified for distribution among the 50 households selected from

above three categories. Each household received both fortified roller mill atta arid fortified hammer mill

atta at 2kg per household totaling 4kg prior to two days of the date of survey conducted.

On the whole our results show that only differences in the fineness of the atta is the determinant regarding

whether hammer mill atta is inferior to roller mill atta. Minor differences in taste and quality are tolerable

considering the prices. This special small survey revealed that roller mill atta is more acceptable due to its

almost zero wastage rate. Respondents also reported that hammer mill atta looked different from both

market atta and roller mill atta. The former is coarser in texture and, slightly yellowish in color due to its

bran contents. The result also showed that the taste and quality of fortified roller mill atta is better than

fortified hammer mill atta currently distributed.

While in terms of dirtiness, respondents revealed that fortified roller mill atta is better (it is in fact due to the

removal of bran). Most respondents opined that the roller mill atta is similar to flour sold in the sealed bags

in the market at high price. When the individuals are asked whether they would buy fortified roller mill atta

or not if free distribution of hammer mill atta is stopped. The answer highlighted some interesting facts.

Respondents reported that if the option were between hammer mill atta and roller mill atta then they would

go for roller mill atta even at 2-3 taka higher prices. The reason is its zero wastage rate. But if the option of

rice is there, they would go for rice which is 3-4 taka cheaper than roller mill atta and due to the in built

eating habits of the Bangladeshi families for centuries.

2

Table 1: Summary of the survey results .

In terms of utilization, the fortified roller mill atta ranks the top. The low utilization was to be held

responsible for coarseness of fortified hammer mill atta. As the distributed atta is coarser, almost every

household tries to sieve it filtering out the bran in the traditional way. This process of extraction of fine atta

often results in considerable wastage. From our present survey it is found that 80% respondents reported

that the loss while sieving is no less than 25% while the same figure for fortified roller mill atta is almost nil

(Table 1).

On the whole, in conjunction with the findings from previous study, this study finds that the atta

fortification project is an economic and effective way of supporting the poor with micronutrient rich

foodstuffs. The roller mill atta is even better if we ignore the opportunity cost of it. If atta is freely

distributed, individuals would prefer roller mill atta. But if they are asked to buy this atta from the market,

survey revealed that they won’t go for roller mill atta. The binary comparison of fortified roller mill and rice

reveals that households would go for rice for two counts- it is 4-5 taka cheaper compared to the roller mill

atta (not fortified) and century long habit. But if they are to choose from fortified hammer mill atta and rice,

the previous study showed that many households revealed that they would go for fortified atta if the

wastage rate can be checked. In this regard, our suggestion was that all currently existing mills have the

capacity to produce refined (fortified) atta and the resultant cost will also be marginal. From RRA it was

found that such refined atta could be supplied at an additional cost of 2-3 per cent only. Hence, it is evident

that though the roller mill atta is acceptable without exception, the cost consideration might restrain the

poor of rural Bangladesh from purchasing it from their own money. While more refined fortified hammer

mill atta can be a substitute for rice if the awareness program is run effectively, the roller mill atta seems to

be considered as a luxury for the poor.

wheat flour fortification program in bangladesh

Documents