Food Fortification in Focus

Why are some foods fortified and others not? Why do we need fortification at all? Explore this section for answers to your questions about food fortification.

What is Fortification?

Codex Alimentarius use both ‘fortification’ and ‘enrichment’ to describe the addition of nutrients to foods.1 Their definition states that: "Fortification or enrichment means the addition of one or more essential nutrients to a food, whether or not it is normally contained in the food, for the purpose of preventing or correcting a demonstrated deficiency of one or more nutrients in the population or specific population groups."

The important thing to note in this globally accepted definition is that fortification is for the purpose of preventing or correcting a demonstrated deficiency – thereby giving fortification its important role in public health.

History of Food Fortification

Food fortification became commonplace during the First and Second World Wars to help prevent nutritional deficiencies within the population, and to replace nutrients that were lost during food processing.2 Many countries in Europe (including Ireland, the UK, Spain and Denmark) and the USA introduced mandatory fortification of foods to increase intake of A, D and B-group vitamins,3 and these practises are still ongoing today.

Food Fortification has been undertaken in the Arab Gulf Region since the late 1970’s. In 1978, KSA became one of the first countries in the region to introduce wheat flour fortification. In the 1990s, several more countries in the region began fortifying wheat flour with encouragement from international organizations such as the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF), and the Micronutrient Initiative (MI). Fortification of wheat flour with iron and folic acid is now mandatory in KSA, Oman, Kuwait and Bahrain and voluntary in Qatar and the UAE.4 More recently KSA has also begun adding vitamin D to wheat flour in order to help correct poor vitamin D status.4

The role of Fortified Foods

Many populations across the world now live in an environment of overconsumption where calorie intakes are exceeding energy expenditure, and the Arab Gulf is no exception. However, intakes of some micronutrients (such as iron, folic acid and Vitamin D) in several of these populations are reported to fall below recommendations.5

Inadequate intakes of micronutrients can potentially be addressed by three different approaches:

Improved nutrition education
 
Increased use of nutritional supplements
 
Food Fortification (either voluntary or mandatory)

A comparative analysis of strategies to improve folic acid intake concluded that dietary education to change dietary habits is difficult, and often food sources of individual micronutrients are limited.6 Encouraging use of nutritional supplements is plagued by low adherence rates, and fortification strategies were found to offer the most cost effective route to improve folic acid intakes and status.6

Nutrition education can help to boost individual micronutrients intakes, and food fortification does not supersede the vital role that nutrition education plays in encouraging individuals and families to make the healthiest food choices that are available to them, however choosing fortified foods can help individuals and families to achieve dietary intake goals.

Effectiveness of Fortification

Results from fortification programmes in the Arab Gulf region, and beyond, demonstrate the effectiveness and the public health benefits arising from mandatory food fortification. Since introducing the obligatory addition of folic acid to wheat flour in 1996, Oman has reported a staggering 70% reduction in cases of Spina Bifida.7 The National Flour Fortification program was launched in Bahrain in 2001, and requires the mandatory addition of iron and folic acid to wheat flour. Tracking data shows significant declines in anaemia among pregnant women and in the prevalence of neural tube birth defects.8 Anaemia among pregnant women dropped from 40% in 1996 to 23% in 2012. The prevalence of neural tube defects declined from 2.6 per 1000 live births to 0.9 per 1000 live births.

The Centers for Disease Control and Prevention (CDC) in the USA has named improvements in maternal and infant health as one of 10 great public health achievements, citing significant reductions in the number of infants born with neural tube defects (NTDs).9 Mandatory fortification of cereal grain products with folic acid began in the USA in 1998, contributing to a 36% reduction in NTDs between 1996 to 2006: preventing an estimated 10,000 NTD-affected pregnancies in a decade, and resulting in a savings of $4.7 billion in direct costs.7

The voluntary addition of vitamins and minerals to appropriate foods has also been shown to be an effective food-based strategy to increase micronutrient intakes and reduce inadequacy - without increasing calorie intake.10

Fortified Foods Help to Meet Nutrient Requirements

Evidence from a range of countries demonstrates that voluntary fortification of foods can play an important role in helping to increase the intake of shortfall micronutrients among both children and adults.

Significant proportions of the European population have micronutrient intakes below estimated average requirements for vitamin D, iron, vitamin A, iodine, magnesium and selenium.11 A review of the efficacy and safety of fortification in Europe has recently concluded that voluntary fortification can reduce the risk of sub-optimal intakes of a range of micronutrients at a population level, and can also improve status for selected micronutrients (e.g. folate, vitamin D and riboflavin) in both children and adults.12 Concerns that food fortification could potentially lead to unacceptably high micronutrient intakes in some individuals were considered, however the authors concluded that the risk of adverse effects occurring in these individuals from exceeding upper intakes levels by modest amounts is low.12

Recent analysis of the ‘What we Eat In America’ dietary intake data has shown that nutrient enriched or fortified foods contributed: half or more of the intakes of vitamin D, thiamin and folate; 20-47% of the intakes of vitamins A & C, riboflavin, niacin, B6, B12 and iron; and 12-18% of the intakes of zinc among children and adolescents.5 Fortified breakfast cereals were the largest contributor of folate and iron intake, and fortified milks the largest contributor to intakes of vitamin A and D, followed in both cases by fortified breakfast cereals.

Which Foods are Most Commonly Fortified?

Any foods made from locally sourced wheat flour in countries benefiting from mandatory fortification will contain higher levels of folic acid and iron, and in the case of KSA, vitamin D. Data from European National Food Surveys shows commonly consumed fortified foods to include: ready-to-eat breakfast cereals, cereal bars, fat spreads, breads, milk and juices.13,14,15,16 In most cases, ready-to-eat breakfast cereals were the most commonly consumed fortified food.

Fortification of Breakfast cereals

Breakfast cereals are common fortified foods across the globe, including in the Arab Gulf. Research has shown that regular consumption of fortified breakfast cereals augments intake of various micronutrients.

 

Kellogg’s recognised that fortification with micronutrients played a vital role in achieving optimal health for all the family and has been voluntarily adding vitamins and minerals to breakfast cereals for over 70 years. In 1938, Kellogg’s launched ‘Pep’, the first cereal to be fortified with B vitamins and vitamin D.

There are many studies on the beneficial impact of fortified breakfast cereals on micronutrient intakes and status across Europe and the USA. Data collected in the Irish National Children’s Food Survey (2003–2004) found that fortified breakfast cereals contributed significantly to intakes of iron (30%), folate (24%) and B-vitamins (17-24%).17 Among Irish Adults, contribution is also high with fortified breakfast cereals providing 10-18% of intakes of iron, total folate, riboflavin, niacin, thiamin, vitamin B6 and vitamin D.18 In the UK, Gibson has found increasing breakfast cereal consumption to be positively associated with greater intakes of iron, folate, vitamin D, calcium, B-vitamins and zinc among children aged 4-18 years.19

In the Spanish enKid study, as intakes of fortified ready-to-eat cereals increased, so did intakes of thiamin, riboflavin, vitamin B6, niacin, folate, calcium, iron and vitamin D.20 There was also a significant association between level of ready-to-eat breakfast cereal consumption and increased likelihood of meeting recommended intake of calcium, iron, thiamin, riboflavin, niacin, vitamin B6, folate and vitamin D.20 Similar results have also been reported among both children and adults in France, Canada, USA and Australia.21,22,23,24,25

While little information is available on the contribution of voluntary fortification to micronutrient intakes in the Arab Gulf, data from Europe and the USA suggest that regular consumption could impact on intake and status of shortfall nutrients such as iron, vitamin D, folic acid and other B vitamins. The potential contribution is recognised by the Food Dome Guidelines for Arab Countries which specifically advises the consumption of more fortified cereals and their products.26

A bowl of Kellogg’s breakfast cereal provides at least 25% of the recommended intake of 6 B-group vitamins (thiamin (B1), riboflavin (B2), niacin (B3), vitamin B6, vitamin B12, folic acid), Vitamin D (in kids and family cereals) and at least 15% of the recommended intake for iron.

 

Click here to download a factsheet on The Benefits of Breakfast

Click here to download a factsheet on The Importance of Iron

Click here to download a factsheet on Vital Vitamin D

References

  1. Codex Alimentarius (1987) General principles for the addition of essential nutrients to foods. Available at www.codexalimentarius.org
  2. Mejia (1994) Fortification of foods: Historical development and current practises. Food & Nutr Bull, 15: 278-281.
  3. Flynn A et al. Intake of selected nutrients from foods, from fortification and from supplements in various European countries. Food Nutr Res 53:10.
  4. Flour Fortification Initiative (2012) Middle East Report Accessed at: http://www.ffinetwork.org/regional_activity/middle_east.php
  5. Berner LA et al (2014) Fortified foods are major contributors to nutrient intakes in diets of US children and adolescents. J Acad Nutr Diet 114: 1009-1023
  6. Samaniego-Vaesken ML et al (2012) Vitamin food fortification today. Food Nutr Res 56: 5459 - DOI: 10.3402/fnr.v56i0.5459
  7. Flour Fortification Initiative (2011) Fifteen years of Fortifying with Folic Acid reduces birth defects; averts healthcare expenses. Available at: http://www.ffinetwork.org/about/stay_informed/publications/documents/FolicAcidBackground.pdf
  8. Flour Fortification Initiative (2012) Newsletter Dec 2012 Anemia and Neural Tube Birth Defects Decline in Bahrain Accessed on line Oct 2014 at: http://www.ffinetwork.org/about/stay_informed/newsletters/Q4_21012.html
  9. Centers for Disease Control and Prevention. Ten Great Public Health Achievements - United States, 2001 º 2010. May 20, 2011. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6019a5.htm
  10. Hannon EM et al (2007) the impact of voluntary fortification of foods on micronutrient intakes in Irish adults. Br J Nutr 97: 1177- 1186.
  11. Mensink GMB et al (2013) Mapping low intake of micronutrients across Europe. Br J Nutr 110: 755-73.
  12. Hennessy A et al (2013) The impact of voluntary food fortification on micronutrient intakes and status in European countries: a review. Proc Nutr Soc 72: 433-440
  13. Hennessy A et al (2011) The contribution of fortified foods to micronutrient intake in Irish Adults aged 18-64 years. Proc Nutr Soc 70: E112
  14. Bonner G et al (1999) Fortification examined: how added nutrients can undermine food Nutrition. London, The Food commission
  15. Hirvonen T et al (2012) Use of voluntarily fortified foods among adults in Finland. Pub Health Nutr 15: 802-810
  16. Wagner KH et al (2005) The role of fortified foods – situation in Austria. Forum Nutr 57: 84-90
  17. Hannon EM & Flynn A (2007) Contribution of ready-to-eat breakfast cereals to nutrient intakes in Irish children aged 5-12 years. Proc Nutr Soc 66: 43A
  18. Galvin et al (2003) Impact of ready-to-eat breakfast cereal (RTEBC) consumption on adequacy of micronutrient intakes and compliance with dietary recommendations in Irish adults. Pub Health Nutr 6: 3512-363
  19. Gibson S (2003) Micronutrient intakes, micronutrient status and lipid profiles among young people consuming different amounts of breakfast cereals: further analysis of data from the national Diet and Nutrition Survey of Young People aged 4 to 18 years. Pub Health Nutr 6: 815-820
  20. Van den Boom A et al (2006) The contribution of ready-to-eat cereals to daily nutrient intake and breakfast quality in a Mediterranean setting. J Am Coll Nutr 25: 135-143
  21. Preziosi P et al (1999) Breakfast type, daily nutrient intakes and vitamin and mineral status of French children, adolescents and adults. J Am Coll Nutr 18:171-178
  22. Barr SI, DiFrancesco L. et al. (2013) Consumption of Breakfast and the Type of Breakfast Consumed Are Positively Associated with Nutrient Intakes and Adequacy of Canadian Adults. J Nutr, 43: 86-92
  23. Barton BA et al (2005) The relationship of breakfast and cereal consumption to nutrient intake and body mass index: the National Heart, Lung, and Blood Institute Growth and Health Study. J Am Diet Assoc 105: 1383–9
  24. Deshmukh-Taskar PR et al (2010) Do breakfast skipping and breakfast type affect energy intake, nutrient intake, nutrient adequacy, and diet quality in young adults? NHANES 1999– 2002. J Am Coll Nutr. 29: 407–18
  25. Grieger JA et al (2012) Comparison of dietary intakes according to breakfast choice in Australian boys. Eur J Clin Nutr. 66: 667–72
  26. Musaiger AO (2012) The Food Dome; dietary guidelines for Arab countries. Nutr Hosp 27: 109-115