From field to bread: quantitative assessment of the implementation and acceptance of zinc biofortified and fortified wheat flour

Abstract Background Micronutrient deficiencies, or hidden hunger remain a global health threat. Biofortification and fortification of staple foods has emerged as a promising approach to address the growing concern posed by hidden hunger. Therefore, in this study, we aimed to assess the current practices surrounding the cultivation and utilization of wheat and wheat flour, and to identify the potential benefits as well as the factors for the adoption of biofortified and fortified wheat flour. Methods We conducted a cross-sectional survey in two districts of Sindh, Pakistan, comprising of two components: household and market. Data was collected between November 25th, 2021, to February 17th, 2022, using mobile-based applications, with field staff trained in standardized data collection methods. The data was analyzed using version 16 of the Stata software. Results A total of 1,915 households and 845 merchandisers were interviewed in the household and market surveys, respectively. Overall, 95.2% of households prepared meals using wheat flour, with higher purchase and costs in Ghotki than TMK. Awareness of fortification (2.9%) and fermentation (17.5%) were very low, and only 12.2% of aware households used fortified wheat flour. While 73.8% of farming households cultivated wheat, only 3.6% knew of biofortified wheat, and 4.4% of these households had cultivated it. However, 53.8% were willing to adopt it for higher nutrient value (62.3%) and better production (48.3%). Among merchandisers, 91.2% were sole proprietors. None of the 84 atta-chakki owners knew about biofortification, and only 1.2% knew about fortification. Conversely, 6 of the 11 (54.5%) large-scale mill owners were aware of fortification, of which 5 (83.3%) had technical training, and all 6 (100%) possessed the required machinery. Key policy and market barriers cited by 100% of millers were a total lack of consumer awareness and low market demand, alongside weak government regulation. Both chakkis and mills expressed strong willingness to switch to biofortified or fortified wheat if given incentives such as free or subsidized provision of wheat grain, micronutrients and minerals, equipment, tools and machinery needed for fortification, with free technical training. Conclusion Uptake of biofortified and fortified wheat products is limited due to poor consumer awareness and weak regulatory enforcement, despite strong stakeholder willingness. Overcoming these sociocultural and market hurdles require targeted public health messaging along with government incentives, subsidized equipment, and technical training for market-based stakeholders.