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.
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.
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
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
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.
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
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.
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.
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