Fortification of Flour and Outcomes: Oman’s Perspective—Contextual Considerations and Outcome
Flour fortification is a recognized strategy for anemia and NTD prevention. The impact is well documented through clinical trials. Oman was the first country in the Middle East to make fortification of flour with folic acid a national compulsory legislation. This chapter discusses the demographic, health, and nutritional context in 1996 when the decision was made, and the impact on anemia among various population groups as well as the impact on NTDs.
More than 80 % of the flour and bread supply in Oman was through one large mill that was well equipped to manage fortification of flour. White flour was fortified at 30 ppm iron and 1.5 folate. The political well was manifested by an expedited legislation and execution of the program. Studies showed that awareness of anemia and fortification was very limited before and after fortification.
Anemia among preschool children at the age of 3–5 years increased by 20 % from 1996 to 2009, whereas the rate among school children went down by 23 % from 1996 to 2004. Women of childbearing age had declined by 0.8 % annually. The rates of NTDs went down by 80 %.
KeywordsFortification Oman Iron Folate Flour fortification Anemia NTDs Spina bifida School children Women Men
United Arab Emirates
Kingdom of Saudi Arabia
Gross Domestic Product
United Nations Children Fund
Protein energy malnutrition
Grams per deciliter
Microgram per deciliter
World Health Organization
Eastern Mediterranean Regional office of the World Health Organization
Centers for Disease Control
United States of America
Parts per million
Metric tons per day
Recommended nutrients intake
Estimated average requirements
Milligram per day
Neural tube defects
Quality adjusted life years
Ministry of Health
- 2.Information DoSa. Annual health report 2009. Muscat: Ministry of Health; 2010.Google Scholar
- 3.CIA. The world fact book. https://www.cia.gov/library/publications/the-world-factbook/geos/mu.html; https://www.cia.gov/library/publications/the-world-factbook/geos/mu.html. 2011 (cited 2011 September 9).
- 5.MONE. Facts and figures 2010. Muscat: Ministry of National Economy; 2011.Google Scholar
- 6.Division UNS, Oman. http://data.un.org/CountryProfile.aspx?crname=Oman; http://data.un.org/CountryProfile.aspx?crname=Oman. 2011 (cited 2011 September 10).
- 7.MiONE. Long term developmental strategy (1996–2020). http://www.moneoman.gov.om/book/vision/english/home_eng.htm; http://www.moneoman.gov.om/book/vision/english/home_eng.htm. 1995 (cited 2011 December 18).
- 8.WHO. World Health report 2000: health systems: improving performance. Geneva: World Health Organization; 2000. ISBN 924156198X.Google Scholar
- 9.information DoSa. Annual health report 2010. Muscat: Ministry of Health; 2012.Google Scholar
- 10.UNICEF. The state of the world’s children 2011. New York: UNICEF; 2011. ISBN 978-92-806-4555-2.Google Scholar
- 12.Amine E. Nutrition status survey in Oman and Bahrain: report of the United Nations Children Fund (UNICEF). Muscat: UNICEF; 1980.Google Scholar
- 13.Mussaigher A. Health and nutritional status of Omani families. Muscat: UNICEF; 1993.Google Scholar
- 14.Alasfoor D, El Sayed MK, Al Qasmi AM, Malankar P, Sheth M, Prakash N. Protein energy malnutrition among pre-school children in Oman, results of a national survey. East Mediterr Health J. 2007;13(5):146–54.Google Scholar
- 15.ElSayed MK, Al-Shamakhi S, Alasfoor D. Analysis report of the second national PEM survey. Muscat: Ministry of Health; 2011.Google Scholar
- 16.Roushdi A, Alasfoor D. Strategy for combating child malnutrition in Oman. Muscat: Ministry of Health; 2004.Google Scholar
- 17.Davidson R. Hemoglobin values in preschool children and pregnant women. Oman Med J. 1986;3(2):38–42.Google Scholar
- 18.Department of Obstetrics, Department of Child Health, National Health Program. Antenatal care. Muscat: Ministry of Health; 1990.Google Scholar
- 19.Al-Riyami A, Afifi A, Al-Kharusi H, Morsi M. National health survey 2000, Reproductive health study, vol. II. Oman: Ministry of Health, the Sultanate of Oman; 2000.Google Scholar
- 20.Abbas KA, Reddy SK. Assignment report: appraisal of vitamin A deficiency. Muscat: MoH; 1981.Google Scholar
- 21.WHO, MoH, UNICEF. National study on the prevalence of vitamin A deficiency (VAD) among children 6 months to 7 years. Muscat: Ministry of Health, World Health Organization, United Nations Children’s Fund; 1994.Google Scholar
- 22.MoH, UNICEF. National vitamin A impact study. Muscat; 1999.Google Scholar
- 23.MoH, SQU, WHO, UNICEF. National study on the prevalence of iodine deficiency disorders. Muscat; 1993.Google Scholar
- 24.Verster A. Guidelines for the control of iron deficiency in countries of the Eastern Mediterranean Middle East and North Africa. Alexandria: World Health Organization; 1996. Report No.: WHO-EM/Nut/177, E/C/11.96/1000.Google Scholar
- 25.Verster A. Consensus statement of participants in joint WHO/UNICEF/MI/PAMM strategy development workshop on food fortification with special reference to iron fortification of flour. Cairo: World Health Organization-EMRO; 1996.Google Scholar
- 26.Verster A. Fortification of flour with iron in countries of the Eastern Mediterranean, Middle East and North Africa. Alexandria: WHO; 1998. Report No.: WHO-EM/Nut/202/E/G.Google Scholar
- 27.Gohar A. Perceptions, attitudes and practices in Oman towards micronutrients deficiencies and food fortification. Cairo: Ministry of Health-Oman, WHO/EMRO, CDC/Atlanta/USA; 2003.Google Scholar
- 28.MoH. National micronutrients status and fortified food coverage report. Muscat: Ministry of Health/Oman, International Micronutrient Malnutrition Prevention and Control Program (IMMPaCT)/CDC/USA, WHO/EMRO; 2009Google Scholar
- 29.WHO. Evaluation of nutritional anemia control programme in the sultanate of Oman. Alexandria: World Health Organization-Eastern Mediterranean Health Office, Maternal and Child Health and Family Health; 1993.Google Scholar
- 30.Moursi M. The 2004 national diet and nutrition survey of the Sultanate of Oman, preliminary report. Muscat: Ministry of Health; 2009.Google Scholar
- 31.Alasfoor D, Rajab H, Al Rassassi B. Food based dietary guidelines, technical background and description. Muscat: Ministry of Health; 2007.Google Scholar
- 32.Agriculture Mo. Food balance sheets. Muscat: Ministry of Agriculture, Directorate General of Agricultural welfare; 1995.Google Scholar
- 33.UNDP. Human development report 2011; sustainability and equity: a better future for all. New York: United Nations Development Program; 2011.Google Scholar
- 34.WHO. Global strategy on infant and young child feeding. Geneva: World Health Organization; 2003.Google Scholar
- 35.Alasfoor D, Rawas S, Al-Farsi Y, Al-Shishtawi M. National study on the role of care in the nutritional status of children under 2 years in Oman. Muscat: Ministry of Health; 2000.Google Scholar
- 36.Alasfoor D. Nutritional anemia and vitamin a deficiency in Oman, a multivariate analysis. Ithaca: Cornell University; 1996.Google Scholar
- 37.e-library of evidence for nutrition actions (e-LENA). [Online]. 2009 [cited 2011 12 30. Available from: http://www.who.int/nutrition/publications/micronutrients/wheat_maize_fort.pdf; http://www.who.int/nutrition/publications/micronutrients/wheat_maize_fort.pdf.
- 39.Benoist BD, Mclean E, Igli I, Cogswell M. Worldwide prevalence of anemia 1993–2005 (WHO global database of anemia). Geneva: World Heath Organization; 2008.Google Scholar
- 40.MOCI. Ministerial decree 88/97: white flour fortification with iron and folate. Muscat: Ministry of Commerce and Industries; 1997.Google Scholar
- 42.UNDP. The real wealth of nations; pathways to human development. New York: United Nations Development Program; 2010.Google Scholar
- 43.The Word Fact Book. https://www.cia.gov/library/publications/the-world-factbook/geos/mu.html; https://www.cia.gov/library/publications/the-world-factbook/geos/mu.html. 2011 (cited 2011 September 9).
- 44.Allen L, De Bonoit B, Dary O, Hurrell R. Guidelines on food fortification with micronutrients. Geneva: World Health Organization and Food and Agriculture Organization of the United Nations; 2006. ISBN 9241594012.Google Scholar
- 45.EMRO-WHO. Evaluation of nutritional anemia control program in the Sultanate of Oman, Report of an evaluation; 1993.Google Scholar
- 46.Lindsay AH. New approaches for designing and evaluating food fortification programs. J Nutr. 2006;136(4):1055–8.Google Scholar
- 47.Ministry of National Economy. http://www.moneoman.gov.om/book/mb/July2010/T1.pdf; http://www.moneoman.gov.om/book/mb/July2010/T1.pdf. 2011 (cited 2011 September 12)
- 48.Suleiman AJ, Al Riyami A, Farid SM. Oman family health survey 1995, principal report. Muscat: Ministry of Health; 2000.Google Scholar
- 49.Emory University. Flour Fortification Initiative. http://www.ffinetwork.org/plan/index.html (cited 2011 December 12).
- 50.Alryami A. National genetic blood survey. Muscat: Ministry of Health; 2000.Google Scholar
- 51.National Center for Statistics and Information, Monthly Statistical Bulletin (Arabic): Supreme Council of Planning- Muscat-Oman. 2011:22(7).Google Scholar
- 52.MoH. Minutes of the food fortification working group on the 3rd of September 1996. Muscat: Department of Nutrition, Ministry of Health; 1996.Google Scholar