Fortification of Flour and Outcomes: Oman’s Perspective—Contextual Considerations and Outcome

  • Deena AlasfoorEmail author
  • Medhat K. ElSayed
Part of the Nutrition and Health book series (NH)


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 %.


Fortification Oman Iron Folate Flour fortification Anemia NTDs Spina bifida School children Women Men 



United Arab Emirates


Kingdom of Saudi Arabia






Gross Domestic Product


United States




United Nations Children Fund


Protein energy malnutrition




Grams per deciliter






International units


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


Omani Rials


Recommended nutrients intake


United Nations


Estimated average requirements


Milligram per day


Neural tube defects


Quality adjusted life years


Ministry of Health


  1. 1.
  2. 2.
    Information DoSa. Annual health report 2009. Muscat: Ministry of Health; 2010.Google Scholar
  3. 3.
  4. 4.
    FAO country profiles: Oman.; 2011 (cited 2011 September 9).
  5. 5.
    MONE. Facts and figures 2010. Muscat: Ministry of National Economy; 2011.Google Scholar
  6. 6.
  7. 7.
    MiONE. Long term developmental strategy (1996–2020).; 1995 (cited 2011 December 18).
  8. 8.
    WHO. World Health report 2000: health systems: improving performance. Geneva: World Health Organization; 2000. ISBN 924156198X.Google Scholar
  9. 9.
    information DoSa. Annual health report 2010. Muscat: Ministry of Health; 2012.Google Scholar
  10. 10.
    UNICEF. The state of the world’s children 2011. New York: UNICEF; 2011. ISBN 978-92-806-4555-2.Google Scholar
  11. 11.
    World Health Organization.; 2011 (cited 2011 December 20).
  12. 12.
    Amine E. Nutrition status survey in Oman and Bahrain: report of the United Nations Children Fund (UNICEF). Muscat: UNICEF; 1980.Google Scholar
  13. 13.
    Mussaigher A. Health and nutritional status of Omani families. Muscat: UNICEF; 1993.Google Scholar
  14. 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. 15.
    ElSayed MK, Al-Shamakhi S, Alasfoor D. Analysis report of the second national PEM survey. Muscat: Ministry of Health; 2011.Google Scholar
  16. 16.
    Roushdi A, Alasfoor D. Strategy for combating child malnutrition in Oman. Muscat: Ministry of Health; 2004.Google Scholar
  17. 17.
    Davidson R. Hemoglobin values in preschool children and pregnant women. Oman Med J. 1986;3(2):38–42.Google Scholar
  18. 18.
    Department of Obstetrics, Department of Child Health, National Health Program. Antenatal care. Muscat: Ministry of Health; 1990.Google Scholar
  19. 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. 20.
    Abbas KA, Reddy SK. Assignment report: appraisal of vitamin A deficiency. Muscat: MoH; 1981.Google Scholar
  21. 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. 22.
    MoH, UNICEF. National vitamin A impact study. Muscat; 1999.Google Scholar
  23. 23.
    MoH, SQU, WHO, UNICEF. National study on the prevalence of iodine deficiency disorders. Muscat; 1993.Google Scholar
  24. 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. 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. 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. 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. 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. 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. 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. 31.
    Alasfoor D, Rajab H, Al Rassassi B. Food based dietary guidelines, technical background and description. Muscat: Ministry of Health; 2007.Google Scholar
  32. 32.
    Agriculture Mo. Food balance sheets. Muscat: Ministry of Agriculture, Directorate General of Agricultural welfare; 1995.Google Scholar
  33. 33.
    UNDP. Human development report 2011; sustainability and equity: a better future for all. New York: United Nations Development Program; 2011.Google Scholar
  34. 34.
    WHO. Global strategy on infant and young child feeding. Geneva: World Health Organization; 2003.Google Scholar
  35. 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. 36.
    Alasfoor D. Nutritional anemia and vitamin a deficiency in Oman, a multivariate analysis. Ithaca: Cornell University; 1996.Google Scholar
  37. 37.
    e-library of evidence for nutrition actions (e-LENA). [Online]. 2009 [cited 2011 12 30. Available from:;
  38. 38.
    Alasfoor D, El Sayed MK, Mohammed AJ. Spina bifida and birth outcomes before and after fortification of flour with iron and folic acid in Oman. East Mediterr Health J. 2010;16(5):533–8.PubMedGoogle Scholar
  39. 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. 40.
    MOCI. Ministerial decree 88/97: white flour fortification with iron and folate. Muscat: Ministry of Commerce and Industries; 1997.Google Scholar
  41. 41.
    Ramakrishnan U, Yip R. Experiences and challenges in industrialized countries: control of iron deficiency in industrialized countries. J Nutr. 2002;132:820S–4.PubMedGoogle Scholar
  42. 42.
    UNDP. The real wealth of nations; pathways to human development. New York: United Nations Development Program; 2010.Google Scholar
  43. 43.
  44. 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. 45.
    EMRO-WHO. Evaluation of nutritional anemia control program in the Sultanate of Oman, Report of an evaluation; 1993.Google Scholar
  46. 46.
    Lindsay AH. New approaches for designing and evaluating food fortification programs. J Nutr. 2006;136(4):1055–8.Google Scholar
  47. 47.
  48. 48.
    Suleiman AJ, Al Riyami A, Farid SM. Oman family health survey 1995, principal report. Muscat: Ministry of Health; 2000.Google Scholar
  49. 49.
    Emory University. Flour Fortification Initiative. (cited 2011 December 12).
  50. 50.
    Alryami A. National genetic blood survey. Muscat: Ministry of Health; 2000.Google Scholar
  51. 51.
    National Center for Statistics and Information, Monthly Statistical Bulletin (Arabic): Supreme Council of Planning- Muscat-Oman. 2011:22(7).Google Scholar
  52. 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

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.Department of NutritionMinistry of HealthAl GhubraOman
  2. 2.Ministry of HealthMuscatOman

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