Food fortification or enrichment is the process of adding micronutrients (essential trace elements and vitamins) to food. It can be purely a commercial choice to provide extra nutrients in a food, or sometimes it is a public health policy which aims to reduce numbers of people with dietary deficiencies in a population.
Diets that lack variety can be deficient in certain nutrients. Sometimes the staple foods of a region can lack particular nutrients, due to the soil of a region, or because of the inherent inadequacy of the normal diet. Addition of micronutrients to staples and condiments can prevent large-scale deficiency diseases in these cases.1
While it is true that both fortification and enrichment refer to the addition of nutrients to food, the true definitions do slightly vary. As defined by the World Health Organization (WHO) and the Food and Agricultural Organization of the United Nations (FAO), fortification refers to "the practice of deliberately increasing the content of an essential micronutrient, ie. vitamins and minerals (including trace elements) in a food irrespective of whether the nutrients were originally in the food before processing or not, so as to improve the nutritional quality of the food supply and to provide a public health benefit with minimal risk to health," whereas enrichment is defined as "synonymous with fortification and refers to the addition of micronutrients to a food which are lost during processing."2
Food fortification was identified as the second strategy of four by the WHO and FAO to begin decreasing the incidence of nutrient deficiencies at the global level.2
As outlined by the FAO, the most common fortified foods are:
- Cereals and cereal based products
- Milk and Milk products
- Fats and oils
- Accessory food items
- Tea and other beverages
- Infant formulas3
The 4 main methods of food fortification (named as to indicate the procedure that is used in order to fortify the food):
- Biofortification (i.e. breeding crops to increase their nutritional value, which can include both conventional selective breeding, and modern genetic modification)
- Microbial biofortification and synthetic biology (i.e. addition of probiotic bacteria to foods)
- Commercial and industrial fortification (i.e. flour, rice, oils (common cooking foods))
- Home fortification (e.g. vitamin D drops)4
The WHO and FAO, among many other nationally recognized organizations, have recognized that there are over 2 billion people worldwide who suffer from a variety of micronutrient deficiencies. In 1992, 159 countries pledged at the FAO/WHO International Conference on Nutrition to make efforts to help combat these issues of micronutrient deficiencies, highlighting the importance of decreasing the number of those with iodine, vitamin A, and iron deficiencies.2 A significant statistic that led to these efforts was the discovery that approximately 1 in 3 people worldwide were at risk for either an iodine, vitamin A, or iron deficiency. Although it is recognized that food fortification alone will not combat this deficiency, it is a step towards reducing the prevalence of these deficiencies and their associated health conditions5
In Canada, The Food and Drug Regulations have outlined specific criterion which justifies food fortification:
- To replace nutrients which were lost during manufacturing of the product (i.e. the manufacturing of flour6)
- To act as a public health intervention
- To ensure the nutritional equivalence of substitute foods (i.e. to make butter and margarine similar in content, soy milk and cow's milk, etc.)
- To ensure the appropriate vitamin and mineral nutrient composition of foods for special dietary purposes (i.e. Boost, gluten-free products, low sodium, or any other products specifically designed for special dietary requirements from an individual).7
There are also several advantages to approaching nutrient deficiencies among populations via food fortification as opposed to other methods. These may include, but are not limited to: treating a population without specific dietary interventions therefore not requiring a change in dietary patterns, continuous delivery of the nutrient, does not require individual compliance, and potential to maintain nutrient stores more efficiently if consumed on a regular basis.4
Several organizations such as the WHO, FAO, Health Canada, and the Nestlé Research Center acknowledge that there are limitations to food fortification. Within the discussion of nutrient deficiencies the topic of nutrient toxicities can also be immediately questioned. Fortification of nutrients in foods may deliver toxic amounts of nutrients to an individual and also cause its associated side effects. As seen with the case of fluoride toxicity below, the result can be irreversible staining to the teeth. Although this may be a minor toxic effect to health, there are several that are more severe.8
The WHO states that limitations to food fortification may include: human rights issues indicating that consumers have the right to choose if they want fortified products or not, the potential for insufficient demand of the fortified product, increased production costs leading to increased retail costs, the potential that the fortified products will still not be a solution to nutrient deficiencies amongst low income populations who may not be able to afford the new product, and children who may not be able to consume adequate amounts thereof.2
Food safety worries led to legislation in Denmark in 2004 restricting foods fortified with extra vitamins or minerals. Products banned include: Rice Crispies, Shreddies, Horlicks, Ovaltine and Marmite.9
Danes said [Kelloggs] Corn Flakes, Rice Krispies and Special K wanted to include "toxic" doses which, if eaten regularly, could damage children's livers and kidneys and harm fetuses in pregnant women.10
One factor that limits the benefits of food fortification is that isolated nutrients added back in to a processed food that has had many of its nutrients removed, does not always result in the added nutrients being as bioavailable as they would be in the original, whole food. An example is skim milk that has had the fat removed, and then had vitamin A and vitamin D added back. Vitamins A and D are both fat soluble and not water soluble, so a person consuming skim milk in the absence of fats may not be able to absorb enough of these vitamins as one would be able to absorb from drinking whole milk.
Phytochemicals such as polyphenols can also impact nutrient absorption.
There is a concern that micronutrients are legally defined in such a way that does not distinguish between different forms, and that fortified foods often have nutrients in a balance that would not occur naturally. For example, in the U.S., food is fortified with folic acid, which is one of the many naturally-occurring forms of folate, and which only contributes a minor amount to the folates occurring in natural foods.11 In many cases, such as with folate, it is an open question of whether or not there are any benefits or risks to consuming folic acid in this form.
In many cases, the micronutrients added to foods in fortification are synthetic.
In some cases, certain forms of micronutrients can be actively toxic in a sufficiently high dose, even if other forms are safe at the same or much higher doses. There are examples of such toxicity in both synthetic and naturally-occurring forms of vitamins. Retinol, the active form of Vitamin A, is toxic in a much lower dose than other forms, such as beta carotene. Menadione, a synthetic form of Vitamin K, is also known to be toxic.12
There are several main groups of food supplements:
- Vitamins and co-vitamins
- Essential minerals
- Essential fatty acids
- Essential amino acids
Many foods and beverages worldwide have been fortified, whether a voluntary action by the product developers or by law. Although some may view these additions as strategic marketing schemes to sell their product, there is a lot of work that must go into a product before simply fortifying it. In order to fortify a product, it must first be proven that the addition of this vitamin or mineral is beneficial to health, safe, and an effective method of delivery. The addition must also abide by all food and labeling regulations and support nutritional rationale. From a food developer's point of view, they also need to consider the costs associated with this new product and whether or not there will be a market to support the change.13
Examples of foods and beverages that have been fortified and shown to have positive health effects:
"Iodine deficiency disorder (IDD) is the single greatest cause of preventable mental retardation. Severe deficiencies cause cretinism, stillbirth and miscarriage. But even mild deficiency can significantly affect the learning ability of populations........ Today over 1 billion people in the world suffer from iodine deficiency, and 38 million babies born every year are not protected from brain damage due to IDD."—Kul Gautam, Deputy Executive Director, UNICEF, October 200714
Iodised salt has been used in the United States since before World War II. It was discovered in 1821 that goiters could be treated by the use of iodized salts. However, it was not until 1916 that the use of iodized salts could be tested in a research trial as a preventative measure against goiters. By 1924, it became readily available in the US.15
In many industrialized countries, the addition of folic acid to flour has prevented a significant number of NTDs in infants. Two common types of NTDs, spina bifida and anencephaly, affect approximately 2500-3000 infants born in the US annually. Research trials have shown the ability to reduce the incidence of NTDs by supplementing pregnant mothers with folic acid by 72%.18
Niacin has been added to bread in the USA since 1938 (when voluntary addition started), a programme which substantially reduced the incidence of pellagra.21 As early as 1755, pellagra was recognized by doctors as being a niacin deficiency disease. Although not officially receiving its name of pellagra until 1771.22 Pellagra was seen amongst poor families who used corn as their main dietary staple. Although corn itself does contain niacin, it is not a bioavailable form unless it undergoes Nixtamalization (treatment with alkali, traditional in Native American cultures) and therefore was not contributing to the overall intake of niacin.23 Although pellagra can still be seen in developing countries, fortification of food with niacin played a huge role in eliminating the prevalence of the disease.22
Diseases associated with niacin deficiency include: Pellagra which consisted of signs and symptoms called the 3D's-"Dermatitis, dementia, and diarrhea. Others may include vascular or gastrointestinal diseases.22
Common diseases which present a high frequency of niacin deficiency: alcoholism, anorexia nervosa, HIV infection, gastrectomy, malabsorptive disorders, certain cancers and their associated treatments.22
Since Vitamin D is a fat soluble vitamin it cannot be added to a wide variety of foods. Foods that it is commonly added to are margarine, vegetable oils and dairy products.24 During the late 1800s, after the discovery of curing conditions of scurvy and beriberi had occurred, researchers were aiming to see if the disease, later known as rickets, could also be cured by food. Their results showed that sunlight exposure and cod liver oil were the cure. It was not until the 1930s that vitamin D was actually linked to curing rickets.25 This discovery led to the fortification of common foods such as milk, margarine, and breakfast cereals. This took the astonishing statistics of approximately 80-90% of children showing varying degrees of bone deformations due to vitamin D deficiency to being a very rare condition.26
Risk factors for vitamin D deficiencies include:
- In infants, being exclusively or primarily breast-fed
- Dark skin
- Living in cold climates and having little sun exposure
- Being elderly
- Covering all or almost all of one's skin while outdoors
- Liberal use of high-SPF sunscreens
- Fat malabsorption syndromes
- Inflammatory bowel diseases
- Obesity 27
Diseases associated with a vitamin D deficiency include rickets, osteoporosis, and certain types of cancer (breast, prostate, colon and ovaries). It has also been associated with increased risks for fractures, heart disease, type 2 diabetes, autoimmune and infectious diseases, asthma and other wheezing disorders, myocardial infarction, hypertension, congestive heart failure, and peripheral vascular disease.26
Although fluoride is not considered an essential mineral, it is seen as crucial in prevention of tooth decay and maintaining adequate dental health.28 In the mid 1900s it was discovered that towns with a high level of fluoride in their water supply was causing the residents' teeth to have both brown spotting and a strange resistance to dental caries. This led to the fortification of water supplies with fluoride with safe amounts to retain the properties of resistance to dental caries but avoid the staining cause by fluorosis (a condition caused by a fluoride toxicity).29
The tolerable upper intake level (UL) set for fluoride ranges from 0.7 mg/day for infants aged 0–6 months and 10 mg/day for adults over the age of 19.
Some other examples of fortified foods:
- Calcium is frequently added to fruit juices, carbonated beverages and rice.30
- White rice is frequently enriched to replace lost nutrients during milling or adding extras in.31
- "Golden rice" is a variety of rice which has been genetically modified to produce beta carotene.32
- Amylase rich flour is utilized for food making to increase dietary consumption.33
Despite having some scientific basis, but with controversial ethics, is the science of using foods and food supplements to achieve a defined health goal. A common example of this use of food supplements is the extent to which body builders will use amino acid mixtures, vitamins and phytochemicals to enhance natural hormone production, increase muscle and reduce fat. The literature is not concrete on an appropriate method for use of fortification for body builders and therefore may not be recommended due to safety concerns.34
There is interest in the use of food supplements in established medical conditions. This nutritional supplementation using foods as medicine (nutraceuticals) has been effectively used in treating disorders affecting the immune system up to and including cancers.35 This goes beyond the definition of "food supplement", but should be included for the sake of completeness.
- World Health Organization and Food and Agriculture Organization of the United Nations Guidelines on food fortification with micronutrients. 2006 [cited on 2011 Oct 30].
- Micronutrient Fortification of Food: Technology and Quality Control
- Liyanage, C.; Hettiarachchi, M. (2011). "Food fortification". Ceylon Medical Journal 56 (3): 124–127. doi:10.4038/cmj.v56i3.3607. PMID 22164753.
- Darnton-Hill, E. (1998). Overview: Rationale and elements of a successful food-fortification programme. Food and Nutrition Bulletin. 19(2):92-100
- Food Safety Network. Food Fortification. 2011 [cited 2011 Oct 30]. Available from: http://www.uoguelph.ca/foodsafetynetwork/food-fortification
- Bruno Waterfield (24 May 2011). "Marmite made illegal in Denmark". The Telegraph.
- James Meikle and Luke Harding (12 August 2004). "Denmark bans Kellogg's vitamins". The Guardian.
- A. David Smith, "Folic acid fortification: the good, the bad, and the puzzle of vitamin", American Society for Clinical Nutrition, Vol. 85, No. 1, 3-5. January 2007.
- Higdon (February 2008). "Vitamin K". Linus Pauling Institute, Oregon State University. Retrieved 2008-04-12.
- http://journals.cambridge.org/download.php?file=%2FPNS%2FPNS49_01%2FS0029665190000106a.pdf&code=bff50d94f640323690aecae20ceafeb1dead link
- Salt Institute. Iodized Salt. 2011 [cited 2011 Oct 30]. Available from: http://www.saltinstitute.org/Uses-benefits/Salt-in-Food/Essential-nutrient/Iodized-salt
- History of Iodized Salt. ICCID. 2011 [cited 2011 Oct 30] Available from: http://www.iccidd.org/pages/protecting-children/fortifying-salt/history-of-salt-iodization.php
- Linus Pauling Institute Micronutrient Research for Optimum Health. Micronutrient Information Center. 2003 [cited 2011 Oct 30]. Available from: http://lpi.oregonstate.edu/infocenter/minerals/iodine/
- The Ohio State University Extension. Extension Fact Sheet. 2004 [cited 2011 Oct 30]. Available from: http://ohioline.osu.edu/hyg-fact/5000/pdf/5553.pdf
- Honein MA, Paulozzi LJ, Mathews TJ, Erickson JD, Wong LY (2001). "Impact of folic acid fortification of the US food supply on the occurrence of neural tube defects". JAMA 285 (23): 2981–6. doi:10.1001/jama.285.23.2981. PMID 11410096.
- Office of Dietary Supplements National Institute of Health. Dietary Supplement Fact Sheet: Folate. [cited 2011 Oct 30] Available from:http://ods.od.nih.gov/factsheets/folate
- Linus Pauling Institute Micronutrient Research for Optimum Health. Micronutrient Information Center. 2002 [cited 2011 Oct 30]. Available from: http://lpi.oregonstate.edu/infocenter/vitamins/fa/
- Park YK, Sempos CT, Barton CN, Vanderveen JE, Yetley EA (2000). "Effectiveness of food fortification in the United States: the case of [[pellagra]]". American journal of public health 90 (5): 727–38. doi:10.2105/AJPH.90.5.727. PMC 1446222. PMID 10800421. Wikilink embedded in URL title (help)
- Prousky, J., Millman, C.G., Kirkland, J.B. Pharmacologic Use of Niacin. Journal of Evidence-Based Complementary & Alternative Medicine. 2001; 16(2): 91-101.
- Linus Pauling Institute Micronutrient Research for Optimum Health. Micronutrient Information Center. 2002 [cited 2011 Oct 30]. Available from: http://lpi.oregonstate.edu/infocenter/vitamins/niacin/
- FAO Agricultural and Consumer Protection. Food Fortification Technology. 1996 [cited 2011 Oct 30]. Available from:http://www.fao.org/docrep/W2840E/w2840e03.htm
- Authors unknown. A dose of vitamin D history. Nature Structural Biology. 2002; 9(2):77.
- Holick, M.F. The Vitamin D Deficiency Pandemic: a Forgotten Hormone Important for Health. Health Reviews. 2010; 32: 267-283.
- Linus Pauling Institute Micronutrient Research for Optimum Health. Micronutrient Information Center. 2004 [cited 2011 Oct 30]. Available from: http://lpi.oregonstate.edu/infocenter/vitamins/vitaminD/
- Linus Pauling Institute Micronutrient Research for Optimum Health. Micronutrient Information Center. 2001 [cited 2011 Oct 30]. Available from: http://lpi.oregonstate.edu/infocenter/minerals/fluoride/
- National Institute of Dental and Craniofacial Research. The Story of Fluoridation. 2011 [cited 2011 Oct 30]. Available from: http://www.nidcr.nih.gov/oralhealth/topics/fluoride/thestoryoffluoridation.htm
- Linus Pauling Institute Micronutrient Research for Optimum Health. Micronutrient Information Center. 2003 [cited 2011 Oct 30]. Available from:http://lpi.oregonstate.edu/infocenter/minerals/calcium/
- USA Rice Federation. Brown and White Rice FAQ's. 2006 [cited 2011 Oct 30]. Available from: http://www.usarice.com/doclib/196/158/3403.pdf
- Dawe,D. Crop Case Study: GMO Golden Rice in Asia with Enhanced Vitamin A Benefits for Consumers. The Journal of Agrobiotechnology Management and Economics. 2007; 10(3): 154-160.
- Hossain, M.I., Wahed, M.A., Ahmed, S. Increased food intake after the addition of amylase-rich flour to supplementary food for malnourished children in rural communities of Bangladesh. Food Nutr Bull. 2005; 26(4):323-9.
- Chromiak, J.A., Antonio, J. Use of amino acids as growth hormone-releasing agents by athletes. Nutrition. 2002; 18(7-8): 657-661
- Agriculture and Agri-Food Canada. Functional Foods and Nutraceuticals. 2011 [cited 2011 Oct 30]. Available from: http://www4.agr.gc.ca/AAFC-AAC/display-afficher.do?id=1170856376710&lang=eng