Iron deficiency anemia (IDA) is the most prevalent nutritional disorder worldwide, affecting approximately 50 percent of children, 42 percent of women and 26 percent of men in developing countries. IDA impairs cognitive development, lowers work capacity, reduces resistance to disease and, in severe cases, can lead to neonatal and maternal mortality.

Alleviating IDA through the fortification of commonly consumed foods can have far-reaching health benefits. However, it has not proven easy to identify iron fortificants that work effectively (e.g., that are readily bioavailable), that will be adopted by industry, and that are opaque to consumers. Iron food
fortificants pose special challenges in this respect. The compounds most readily absorbed during digestion also tend to react negatively with foods, causing taste and color changes and accelerating rancidity. While elemental iron powders pose few of these organoleptic problems, significant confusion exists about their absorption during digestion, hence value to iron-deficient populations.

SUSTAIN began to explore the potential for iron fortification of corn masa flour in Central America following technical assessments in 1996 and 1997 of iron fortification practices at wheat mills in El Salvador, Guatemala, Nicaragua and Honduras. In the course of these assessments, the SUSTAIN team also visited two plants that were manufacturing corn masa flour (CMF), a widely available and increasingly popular product used to make tortillas in Mexico and Central America, and a promising new vehicle for iron fortification. In a review of existing scientific literature and industrial experience with fortification of corn masa flour, SUSTAIN found that no published literature existed on the subject; and that knowledge about CMF fortification was very limited generally.

SUSTAIN convened a technical advisory panel of specialists from the corn masa flour industry, scientific institutions and governments to consider the range of issues relevant to the product's fortification. Based on their recommendations that a range of iron compounds be screened for consumer availability, storage characteristics and bioavailability, we sponsored several phases of research.

In 1998, a groundbreaking agreement was signed between industry and government representatives in Mexico to fortify both wheat and corn masa flour with iron and other micronutrients. However, enforceable regulatory action stalled as parties to the agreement questioned which iron fortificant should be required as an additive. Following SUSTAIN's initial research, more was known about the characteristics of some of the more soluble iron fortificants in corn masa flour, but questions remained about their cost and consumer acceptability. Moreover, much remained to be learned about the
bioavailability of the elemental iron powders favored by industry.

In late 1999 and early 2000, SUSTAIN held a number of planning meetings with industry, government and public health representatives in Mexico to examine the issues that appeared to be impeding progress on fortification initiatives and programs. Participants cited confusion and conflicting data regarding the efficacy of elemental iron powders--the most commonly used iron fortificants worldwide--as an impediment to fortification initiatives and to government/industry cooperation to alleviate IDA. Both industries and government representatives asked SUSTAIN to help address this situation.

In response, SUSTAIN convened a panel of world renowned research scientists, physicians and industry specialists to review nearly 45 years of research on the nature of elemental iron powders and to discuss how to interpret conflicting bioavailability data. The Monterrey (Mexico) Workshop
proved to be a highly effective step toward clarification.