In the Middle East, policies regarding bread fortification vary across countries, ranging from voluntary initiatives to mandatory programs, each tailored to address specific nutritional deficiencies and improve public health outcomes (23–25). Qatar, for example, has voluntary fortification initiatives in place since 2015, achieving 90% coverage through industrial mills (23, 26, 27). Similarly, Saudi Arabia has fortified all industrially milled flour with essential nutrients since 2015, achieving 100% coverage and the potential for significant health impact (23, 24).

Also, in Kuwait, the voluntary fortification program was legislated in 2015 mandates the fortification of wheat flour with many nutrients, and it achieves full coverage through a single industrial mill (23, 26). Reflecting a program that is well-established and closely monitored. In the United Arab Emirates (UAE), a voluntary program has resulted in 90% of industrially milled flour being fortified with essential nutrients (23, 24, 26). In 2000, Iraq introduced voluntary flour legislation under the governance of Iraqi Standard Specification (28), later receiving UNICEF support in 2006 aimed at combating nutritional deficiencies (26), despite legislative efforts and the presence of 300 industrial mills processing all flour, none of the industrially milled flour undergoes fortification, resulting in a 0% fortification rate in this sector (23) In contrast to these voluntary approaches, Oman stands out with its longstanding mandatory fortification program initiated in 1996 (27) and implemented the wheat flour legislation in 1997. In 2010, Oman integrated iron and folic acid into all domestically produced and imported wheat flour, while in 2022, new regulations expanded fortification to include various flour types and additional nutrients like vitamin D3 and vitamin B12 (29). Comprehensive legislation and integration into the health financing system ensure broad coverage and sustainability. Almost all (89% according to Food Fortification Initiative; FFI) wheat flour is industrially processed and available for fortification (23, 24). Bahrain similarly enforced mandatory wheat fortification in 2002 (24), targeting anemia and neural tube defects, yet faces challenges such as low coverage among small-scale mills (26, 27). However, 90% of the industrial flour is fortified in Bahrain according to FFI (23, 24). Meanwhile, Yemen has required 100% of industrially milled wheat flour to be mandatorily fortified with iron since 2001, following WHO recommendations to address nutrient deficiencies in vulnerable populations (23, 26). In Iran, wheat flour fortification has been mandatory since 2006. This covers all domestically produced wheat flour types, including all domestically produced wheat flour types, with a reported coverage of 335 grams per capita per day (24, 27). Moreover, A national flour program for fortifying has been initiated in Jordan since April 2006 (26), while the mandatory legislation was implemented in 2008 (24), achieving 93% coverage and significantly reducing iron deficiency and anemia, serving as a regional model emphasizing coordinated efforts and sustainable funding (23, 26). Since 2005, Palestine has mandated fortification (30), despite challenges that Palestine faces, such as insufficient data on coverage and intake (26).

In Syria and Lebanon, the absence of comprehensive fortification programs, particularly in wheat flour, poses a public health concern, placing the population, especially vulnerable groups, at risk of various health issues (24, 27). In Syria, a wheat flour fortification program initiated in 2003 showed promising results by 2009 in reducing iron-deficiency anemia, but it was suspended in 2011 due to the crisis, leading to a setback in expertise and momentum (31). Meanwhile, Lebanon’s lack of fortification legislation for flour is due to disagreements that led to discussions on recommending fortification, addressing barriers, and exploring fluoridation. Similarly, Türkiye lacks a national program to fortify wheat flour. All flour produced in the country is from industrial mills without fortification (24). However, there are indications of a possible mandatory fortification program in the future (27).

In the Middle East, wheat flour fortification standards vary across different countries, yet they share commonalities in addressing nutritional deficiencies and improving public health outcomes (32). These standards are established based on international guidelines and recommendations, ensuring safety and effectiveness in fortification practices (26, 27). Wheat flour fortification typically includes essential nutrients such as iron, folic acid, and B-complex vitamins tailored to meet population needs (2, 33). Fortification standards for wheat flour vary across countries, each with its own set of regulations and compliance measures.

Wheat flour fortification standards in Qatar, Saudi Arabia, the UAE, and Kuwait mirror each other, following the GCC (Gulf Cooperation Council) Standardization Organization (GSO) standards (24), this standard aims to address nutritional deficiencies and requires food products for dietary use to have nutrition fact panels (23, 27, 34). Specifically, these countries fortify wheat flour with calcium (2,115 mg/kg), folic acid (1.75 mg/kg), iron (30 mg/kg), niacin (52.91 mg/kg), riboflavin (3.96 mg/kg), thiamine (6.38 mg/kg), and vitamin D (0.0137 mg/kg) to address common deficiencies and enhance public health (24). These standards are in line with international recommendations and serve as vital regulatory frameworks ensuring consistency and effectiveness across the region (27). While in Iraq, the voluntary fortification of wheat has standards for wheat, including adding folic acid at a level of 2.1 mg/kg and adding ferrous sulfate at a level of 45 mg/kg (24). However, local flour lacks iron fortification, while imported flour meets Iraqi standards (27). Iron and folic acid in flour help reduce anemia cases and have health benefits (16).

The mandatory fortification standard in Oman includes folic acid 1.5 mg/kg and 60 to 120 mg/kg iron (23, 24). Similarly, Bahrain’s mandatory fortified wheat flour with 1.5 mg/kg of folic acid and 60 mg/kg of iron aims to reduce anemia and neural tube defect rates (24, 26). In addition, Yemen enforces mandatory fortification of all industrial wheat flour, incorporating iron and folic acid to combat widespread nutrient deficiencies (26), particularly among vulnerable populations like children and pregnant women (27). The government’s resolution, issued by the Prime Minister in 2001, made it mandatory for wheat flour to be fortified (14). The fortification standards include folate (1.5 mg/kg) and iron (60 mg/kg), with all wheat flour being fortified (14). In Jordan, the fortification standards include essential nutrients such as 34 mg/kg of iron in the form of ferrous sulfate, 14.15 mg/kg of calcium, 1.52 mg/kg of folic acid, 20 mg/kg of zinc, 0.008 mg/kg of vitamin B12, 35 mg/kg of niacin, 3.6 mg/kg of riboflavin, 2.89 mg/kg thiamine, and 1.5 mg/kg of vitamin A (24, 33). In Palestine, mandatory fortification of wheat began in September 2005 (30); while fortifying the wheat flour with 3.6 mg/kg of vitamin B6, Palestine shares other nutrients added to the wheat flour in the same content as Jordan (24).

Lebanon currently lacks both mandatory and voluntary wheat flour fortification programs (26). However, the daily per capita wheat flour consumption of 233 grams presents a significant opportunity for potential fortification interventions (24). Syria presents a contrasting scenario, where fortification data is limited, highlighting the need for improved implementation (24). Despite an industrial processing rate of 82%, only 5% of wheat flour undergoes fortification, indicating substantial room for enhancement (24, 27). Türkiye currently also lacks standards for wheat fortification due to the absence of a national fortification program for wheat flour (24, 27).

In a broader context, fortification standards in the Middle East are developed based on population needs and international guidelines to ensure safety and effectiveness. These standards encompass recommended amounts and permissible ranges of added nutrients, considering factors such as bioavailability and organoleptic characteristics to optimize health benefits while minimizing the risk of toxicity. Furthermore, labeling requirements, claims, and advertising guidelines are integral components of these standards, serving to inform consumers about the fortified products and promote transparency in the marketplace. The fortification standards of different countries are summarized in Table 2.

Compliance and enforcement mechanisms for wheat flour fortification policies in the Middle East are crucial for addressing nutritional deficiencies and improving public health outcomes. Regulatory oversight varies across countries, but common mechanisms include government inspections (32, 35). Additionally, in various Middle Eastern countries, regulatory oversight is typically overseen by government agencies or ministries responsible for public health, food safety, or standardization (26, 27, 30, 35). For instance, in Qatar, the Ministry of Public Health (MOPH) oversees compliance and enforcement of wheat fortification regulations (36). Similarly, in Jordan, the Ministry of Health is responsible for the implementation of fortification programs, with the Jordan Food and Drug Administration (JFDA) monitoring compliance with regulations (2, 35). These governmental bodies often conduct inspections and technical audits at flourmills to ensure compliance with fortification standards (26, 27, 35). Manufacturers must follow Good Manufacturing Practices (GMP), Hazard Analysis and Critical Control Points (HACCP), or International Organization for Standardization (ISO) guidelines to fortify products and ensure safety (26).

Kuwait achieves full compliance through rigorous monitoring and quality control processes despite the absence of mandatory fortification (27). In contrast, some countries have specific legislation mandating fortification, such as Bahrain, Iran, Jordan, Oman, Palestine, and Yemen, where fortification is mandatory by law (24). Integrating it into the health financing system and enforcing compliance through government regulations and monitoring efforts (27). In addition, in Bahrain, the Public Health Directorate’s food inspection section conducts regular monitoring and enforcement by visiting mills every 2 months to ensure a high compliance rate, with compliance rates typically exceeding 90% (26). Noncompliance penalties may vary across countries and include fines, operations closure, or other regulatory actions (26). In Jordan, for example, bakeries found to be operating without a license, not following process hygiene regulations, or using non-fortified flour may face fines or closure of their operations (2).

Despite these efforts, challenges persist in ensuring widespread compliance. In Iraq, compliance with fortification standards is reported to be at 0%, indicating a lack of fortification in locally produced flour (28). Moreover, compliance with fortification programs in Palestine faces significant challenges, including low adherence rates despite mandatory legislation and ongoing monitoring efforts (26), despite the reported 100% coverage (24). Similarly, in Syria, compliance with fortification standards is low, with only 5% of flour estimated to be fortified. Still, given that 82% of wheat flour is industrially processed, there is significant potential for fortification to improve national health outcomes (24, 26, 27). In Lebanon, there is no fortification program, which requires policy reforms and better monitoring. However, difficulties such as standardizing, coordinating, and testing for iron in wheat flour make it challenging and costly (24, 26) Although there is currently no wheat legislation in Türkiye (24), the Turkish Flour Industrialists’ Federation (TFIF) is promoting the adoption of fortification practices by fortifying wheat flour (37).

Iron deficiency is a major concern in this region contributing to a global health challenge known as iron deficiency anemia which mainly effects children, pregnant women, and individuals in low-income countries. The prevalence of iron deficiency varies across countries in the Middle East. According to 2019 survey the prevalence of anemia in Egypt is 28.3% among women of reproductive age (15–49 y); 32.3% among children under five; 26.0% among pregnant women; and 28.4% among non-pregnant women (41). Current prevalence of each country is mentioned in the supplementary material.

Iron plays a crucial role in immune function and red blood cell production therefore its deficiency compromises the body’s ability to combat infections and transport oxygen to tissues leading to fatigue, weakness, and impaired cognitive development in children. Targeted dietary interventions are critical in addressing this issue and mitigating its impact (42, 43). Fortifying bread with Iron is a promising strategy to increase overall iron intake and improve iron status.

A study in Iran evaluating the impact of iron-fortified bread found that while it improved serum ferritin levels, it did not significantly reduce anemia rates. Similarly, ‘Before-and-after’ studies on the flour fortification program with iron in Bushehr and Golestan provinces, involving 600 and 652 women respectively, showed a beneficial effect on ferritin levels but did not significantly alter the prevalence of iron-deficiency anemia in either province (44, 45). It can be justified through various reasons. Firstly, flour fortification of Iron only addresses anemia caused by iron deficiency, but Anemia can also be caused by other micronutrient deficiencies. Secondly, increased inflammation due to infection and obesity can reduce iron absorption. Thirdly, Iron fortification compounds have varying absorption capacity some foods undergo undesirable color or flavor changes when iron is added, and many iron-fortified foods contain inhibitors of iron absorption (46). Specific iron compounds, such as sodium iron (III) ethylenediaminetetraacetate, offer advantages as they enhance absorption even from high phytate foods, which can otherwise hinder iron uptake (47). However, acceptable daily intake (ADI) for humans is 1.9 mg per kg of body weight per day (48). Therefore, improving sanitary practices and infection control, ensuring clean drinking water, and reducing obesity rates will likely have a more significant impact on improving iron levels and reducing anemia in these regions.

The success of Jordan’s iron-fortified bread program is evident in the reduction of both iron deficiency and iron deficiency anemia (IDA). According to the Jordan National Micronutrient Survey (JNMNS) 2019 out of total participants only 28.6 and 10.7% had iron deficiency and iron deficiency anemia respectively, which is less than previous estimate of 2002–2010 survey. In addition, the survey also found that Children aged 12–59 months obtained about two-thirds of their recommended iron intake from fortified bread (49, 50) Moreover, a recent study that looked at the side effects of fortification of Iron in commonly used types of Iranian flour and bread (Barbary, Lavash, and Tafton) in Isfahan, Iran, found that for adults, the risk of getting too much Iron from eating fortified bread was low. However, a study in Semnan, Iran, found that flour fortification with iron led to reduced antioxidant capacity and increased oxidative stress biomarkers in non-anemic healthy men, although no symptoms of iron overload were observed (11). For children, who are more sensitive to Iron, the risk was higher and could be harmful. The researchers suggested more studies that should be done to make sure that the iron levels in fortified bread are safe, especially for children (51). In addition, Mohammadi et al. explored iron levels in wheat flour, a critical dietary source in iron-deficient Iran. Iron content in various Tehran wheat flours fell short of the Iranian health ministry’s minimum requirement of 40 ppm despite fortification with 30-ppm ferrous sulfate. Furthermore, the study revealed variations in iron content between different flour types (52). These findings emphasize the need for stricter monitoring and potentially revised fortification strategies by ensuring adequate iron compound selection, proper fortification levels, and consistent monitoring across all flour varieties, countries as Iran can harness the full potential of flour fortification to combat iron deficiency and its associated health problems.

Some experts worried that low-income individuals might consume too much Iron from fortified bread, leading to iron overload and potential harm to individuals with certain medical conditions. However, research and survey data showed that fortification was effective in combating iron deficiency without causing harm, although ongoing research was monitoring for potential iron overload (53).

Zinc is a crucial mineral for maintaining immunity, growth, and development. It is important to maintain a consistent dietary intake of zinc as our bodies do not store zinc efficiently. Zinc deficiency can lead to stunted growth, weakened immunity, and slow wound healing, especially among children in the Middle East, where micronutrient deficiencies are prevalent. Palestine has the highest prevalence of zinc deficiency among preschool-age children at 55.6%, with female adolescents accounting for 70% and male adolescents at 58.6%, as well as pregnant women at 71.1%. Meanwhile, Somalia has the lowest prevalence of zinc deficiency among preschool-age children at 5%. However, Afghanistan reported a higher zinc deficiency prevalence than Jordan, with rates of 23.4 and 22.1%, respectively, among women of reproductive age. The zinc deficiency rate among pregnant women in Pakistan and Iran is 37.2 and 28%, respectively (8).

Food fortification, which involves adding zinc to processed food, is a cost-effective solution to this problem (54–56). Zinc fortification of bread has been an effective strategy to address zinc deficiency. In Iran, a randomized clinical trial was done to assess the effect of consuming zinc-fortified bread on serum zinc and iron status of zinc-deficient women. Results showed that the group consuming high-zinc bread had significantly greater zinc and iron absorption compared to the low-zinc group. The study concluded that fortifying flour with 50–100 ppm zinc was effective in improving zinc intake and absorption in zinc-deficient individuals. Additionally, consuming zinc-fortified bread improved iron absorption (57). Estimates show that the consumption of Iranian flat breads can provide around 3.5 mg of zinc per person per day, making breads a reliable source of dietary zinc (58). Zinc fortified bread was also introduced in Türkiye. In a study, school children with low serum zinc concentrations received zinc-fortified bread providing 2 mg/kg/day for 90 days, whereas the other children received the same quality bread with no zinc fortification (control group). Results showed that by the end of the period, the zinc-supplemented group had significantly higher serum and leukocyte zinc concentrations indicating that the bioavailability of zinc in the bread is satisfactory, and the use of zinc-fortified bread is an accessible method to eliminate zinc deficiency and to prevent further occurrence (59).

Vitamin D is crucial for bone and muscle health, functioning more like a hormone by regulating calcium and phosphate levels in the body. Deficiency can result in bone osteomalacia in adults and rickets in children. Recent studies have associated low vitamin D levels with an increased risk of chronic diseases like cancer, high blood pressure, and autoimmune disorders (60, 61). In the Middle East, despite the abundant year-long sunshine, there is a high prevalence of vitamin D deficiency and inadequacy. Traditional clothing that covers most of the body and the lack of foods that are either rich in vitamin D or fortified with it can contribute. When reviewing the available data on vitamin D deficiency in Middle Eastern countries, it was challenging to make comparisons due to the use of diverse cut-off points to define deficiency and the varied assays used to measure it. In different countries, the levels of vitamin D deficiency and insufficiency vary widely among various age groups. In Jordan, both preschool and school-age children have high deficiency rates (27.7 and 44.2%, respectively) and insufficiency rates (44.2 and 43.3%, respectively). Afghanistan follows with a significant deficiency among preschool children (16.8%) and high insufficiency rates across all age groups (64.2% in preschool children and 64.7% in non-pregnant women). Palestine reports lower deficiency rates (6% in preschool children) but higher insufficiency rates (54.7% in preschool children and 99.3% in pregnant women). Oman shows a moderate prevalence of insufficiency (53.8% in preschool children and 41.5% in non-pregnant women). Morocco presents lower insufficiency rates compared to other countries (23.4% in preschool children and 47.5% in non-pregnant women). Iraq records severe deficiency among non-pregnant women (74.5%), while Pakistan reports high insufficiency rates (54% in preschool children and 85.3% in pregnant women). Iran’s data primarily focuses on pregnant women and shows a combined rate of insufficiency and deficiency of 81.2% (8). To address these, researchers explored vitamin D-fortified bread.

A randomized double-blind trial was done to assess the bioavailability of vitamin D from fortified Iranian bread and its effects on health. 90 healthy participants aged 20 to 60 years were divided into 3 groups: The fortified bread group (FP), the Placebo group (vitamin D supplement-SP), and the Plain bread group (CP) over 8 weeks. Results showed that changes in serum 25-hydroxyvitamin D concentrations were significant in the FP and SP groups, increasing by 39.0 ± 22.6 nmol/L and 28.9 ± 31.2 nmol/L, respectively, compared to a decrease of 9.2 ± 12.3 nmol/L in the CP group. The study concluded that vitamin D-fortified bread could effectively increase circulating 25-hydroxyvitamin D levels in the population to an adequate level, and it also showed potential benefits for other health aspects such as PTH levels, visceral fat, and lipid profile (62). Moreover, in a systemic review showed that vitamin D-fortified bread is a promising vehicle for fortification strategy effects, leading to increased serum concentrations of 25(OH)D and decreased parathyroid hormone (63). Studies show mixed attitudes toward vitamin D-fortified bread, with sensory changes impacting acceptance (64).

Vitamin A is crucial for vision, growth, and immune function, existing in two forms: preformed vitamin A from animal products and provitamin A carotenoids from plants. Inadequate levels can lead to night blindness, dry eyes, and weakened immunity. Vitamin A plays a vital role in cell growth, development, and maintaining healthy skin and mucous membranes. It is essential for fetal development and a strong immune system, particularly in low-and middle-income countries where deficiency is a major public health concern for young children, pregnant women, and women of reproductive age (4, 65–67). According to national survey done in Jordan at 2019, prevalence of vitamin A deficiency was 4–8% depending on serum retinol or RBP. There were no difference among household wealth, residence or sex (49).

Limited data is available on the impact of vitamin A-fortified bread in the Middle East since the countries fortifying bread with Vitamin A are only Jordan and Palestine.

B vitamins are essential for energy, brain function, and healthy nerves. Deficiencies in specific B vitamins, especially folate (B9) and cobalamin (B12), can lead to health issues. Pregnant women with folate deficiency have an increased risk of birth defects such as NTDs. Deficiencies in B9 and B12 can cause nerve damage, anemia, and may be linked to heart disease. A balanced diet rich in whole grains, vegetables, and animal products is recommended for adequate B vitamin intake. Fortifying bread with B vitamins can also help prevent deficiencies (6, 68, 69). A mandatory flour fortification policy with folic acid was implemented in Iran at one province in 2001 which expanded drastically to prevent the incidence of NTDs (53). A longitudinal hospital-based study coupled with two cross sectional study were conducted before (2006) and after flour fortification (2008) to assess the impact of folate fortification on NTDs and folate status in women of childbearing age involved 13,361 postpartum women longitudinally and 580 women cross-section. This study found a significant increase in folate intake after fortification, with fortified bread contributing an average of 226 μg/day. The total folate intake increased significantly from 198.3 to 413.7 μg/day. The mean Serum folate levels increased from 13.6 to 18.1 nmoL/L, folate deficiency decreased from 14.3 to 2.3%, and NTDs decreased by 31% significantly. The study concluded that mandatory flour fortification with folic acid can significantly increase serum folate levels and decrease the incidence of NTDs (53).

Initially, Fortification of bread with folate was implemented in Egypt at 2008 which was triggered by Egyptian Demographic and Health Survey (EDHS) results and showed an increases in daily folate intake of approximately 600 μg (20), however wheat flour fortification program in Egypt was ceased in 2014. Despite the challenges, Egypt’s Ministry of supply and Internal Trade (MOSIT) continues to partner with FFI to restart the program (70). A study assessing the increased folate content in Egyptian pita bread and Baladi bread found that both types were acceptable to consumers. Consumption of these fortified breads could increase average daily folate intake by 75 μg and 50 mg/100 g, respectively. However, the folate content in fortified breads was lower than the threshold level needed to decrease the incidence of NTDs. This suggests the need for further studies to assess the effectiveness of this threshold in reducing NTDs (71–73). Another study analyzed the folic acid content of wheat and soybean flour added to Baladi bread. The study found that the folic acid content in wheat flour was significantly lower than in soybean flour. After baking, the folic acid content decreased in all breads. However, the study did not explicitly state that fortifying wheat flour with folic acid is less effective than fortifying soy flour. Further studies are needed to explore the folate content and effectiveness of fortification in different flours in this region (74).

In contrast, an observational study conducted in Oman by Alasfoor et al. examined the impact of folic acid fortification in flour on birth outcomes over 15 years, from 1991 to 2006. The study analyzed the national policy that included folic acid supplementation for pregnant women in 1990 and fortified flour with folic acid in 1996. The findings of the study revealed a dramatic decline in the incidence of spina bifida, a serious neural tube defect. Prior to the fortification initiative, the rate of spina bifida ranged between 2.34 and 4.03 per 1,000 deliveries. After the implementation of the fortification, there was a sharp decline in spina bifida incidence, with rates falling from 3.06 per 1,000 deliveries in 1996 to 2.11 in 1997. By 2006, this rate had plummeted to just 0.29 per 1,000 deliveries (75). Additionally, fortifying flour with folic acid at current instance shows a decrease percentage in neural tube defects incidence per 1,000 births in KSA, Oman and Iran are (60, 70 and 31%, respectively), based on FFI report (17). This substantial decline suggests that folic acid fortification could be a valuable public health strategy for reducing birth defects when implemented with adequate fortification levels and consistent monitoring (Table 3).