Food fortification
Encyclopedia
Food fortification or enrichment is the process of adding micronutrient
Micronutrient
Micronutrients are nutrients required by humans and other living things throughout life in small quantities to orchestrate a whole range of physiological functions, but which the organism itself cannot produce. For people, they include dietary trace minerals in amounts generally less than 100...

s (essential trace elements and vitamins) to food
Food
Food is any substance consumed to provide nutritional support for the body. It is usually of plant or animal origin, and contains essential nutrients, such as carbohydrates, fats, proteins, vitamins, or minerals...

. It can be purely a commercial choice to provide extra nutrients in a food, or sometimes it is a public health
Public health
Public health is "the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals" . It is concerned with threats to health based on population 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 food
Staple food
A staple food is one that is eaten regularly and in such quantities that it constitutes a dominant portion of a diet, and that supplies a high proportion of energy and nutrient needs. Most people live on a diet based on one or more staples...

s of a region can lack particular nutrients, due to the soil of a region, or because of the inherent inadequacy of the diet. Addition of micronutrients to staples and condiments can prevent large-scale deficiency diseases in these cases.

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
World Health Organization
The World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...

 (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.

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.

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 formulas

Types of Food Fortification

The 4 main methods of food fortification (named as to indicate the procedure that is used in order to fortify the food):
  1. Biofortification (ie. creating new crops using genetically modified breeding techniques)
  2. Microbial biofortification and synthetic biology (ie. addition of probiotic bacteria to foods)
  3. Commercial and industrial fortification (ie. flour, rice, oils (common cooking foods))
  4. Home fortification (ie. vitamin D drops)

Rationale

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. 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 there associated health conditions

In Canada, The Food and Drug Regulations have outlined specific criterion which justifies food fortification:
  1. To replace nutrients which were lost during manufacturing of the product (ie. the manufacturing of flour)
  2. To act as a public health intervention
  3. To ensure the nutritional equivalence of substitute foods (ie. to make butter and margarine similar in content, soy milk and cow's milk, etc.)
  4. To ensure the appropriate vitamin and mineral nutrient composition of foods for special dietary purposes (ie. Boost, gluten-free products, low sodium, or any other products specifically designed for special dietary requirements from an individual).


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.

Criticism

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
Fluoride
Fluoride is the anion F−, the reduced form of fluorine when as an ion and when bonded to another element. Both organofluorine compounds and inorganic fluorine containing compounds are called fluorides. Fluoride, like other halides, is a monovalent ion . Its compounds often have properties that are...

 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.
The WHO states that limitations to food fortification may include human rights issues indicating that consumers has the right to choose if they want fortified products or not, potential for insufficient demand of the fortified product, increased production costs that may lead increase retail costs, and 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.
Food safety worries led to legislation in Denmark in 2004 restricting foods fortified with extra vitamins or minerals. Products banned include: Rice Crispies, Shreddies
Shreddies
Shreddies is a breakfast cereal sold in the United Kingdom, Ireland, Canada, New Zealand and Germany produced by Post Cereals and General Mills, consisting of malted squares of inter-woven whole grain wheat.Shreddies has been made in the UK since 1955...

, Horlicks
Horlicks
Horlicks is the name of a company and of a malted milk hot drink. It is manufactured by GlaxoSmithKline in the United Kingdom, South Africa, New Zealand, Bangladesh, India, Pakistan and Jamaica, and under licence in the Philippines and Malaysia....

, Ovaltine
Ovaltine
Ovaltine is a brand of milk flavoring product made with malt extract , sugar , cocoa, and whey...

 and Marmite
Marmite
Marmite is the name given to two similar food spreads: the original British version, first produced in the United Kingdom and later South Africa, and a version produced in New Zealand...

.
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 foetuses in pregnant women.

Food supplements

There are several main groups of food supplements:
  • Vitamin
    Vitamin
    A vitamin is an organic compound required as a nutrient in tiny amounts by an organism. In other words, an organic chemical compound is called a vitamin when it cannot be synthesized in sufficient quantities by an organism, and must be obtained from the diet. Thus, the term is conditional both on...

    s and co-vitamins
  • Essential minerals
  • Essential fatty acid
    Essential fatty acid
    Essential fatty acids, or EFAs, are fatty acids that humans and other animals must ingest because the body requires them for good health but cannot synthesize them...

    s
  • Essential amino acid
    Essential amino acid
    An essential amino acid or indispensable amino acid is an amino acid that cannot be synthesized de novo by the organism , and therefore must be supplied in the diet.-Essentiality vs. conditional essentiality in humans:...

    s
  • Phytonutrients
  • Enzyme
    Enzyme
    Enzymes are proteins that catalyze chemical reactions. In enzymatic reactions, the molecules at the beginning of the process, called substrates, are converted into different molecules, called products. Almost all chemical reactions in a biological cell need enzymes in order to occur at rates...

    s

Examples of fortified foods

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.

Examples of foods and beverages that have been fortified and shown to have positive health effects:

Iodized Salt

"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 2007
Iodised salt
Iodised salt
Iodised salt is table salt mixed with a minute amount of various iodine-containing salts. The ingestion of iodide prevents iodine deficiency. Worldwide, iodine deficiency affects about two billion people and is the leading preventable cause of mental retardation. It also causes thyroid gland...

 has been used in the United States
United States
The United States of America is a federal constitutional republic comprising fifty states and a federal district...

 since before World War II
World War II
World War II, or the Second World War , was a global conflict lasting from 1939 to 1945, involving most of the world's nations—including all of the great powers—eventually forming two opposing military alliances: the Allies and the Axis...

. 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.

Currently in Canada and the US, the RDA
RDA
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 for iodine is as low as 90mcg/day for children (4-8 years) and as high as 290mcg/day for breast-feeding mothers.

Diseases that are associated with an iodine deficiency include: mental retardation
Mental retardation
Mental retardation is a generalized disorder appearing before adulthood, characterized by significantly impaired cognitive functioning and deficits in two or more adaptive behaviors...

, hypothyroidism
Hypothyroidism
Hypothyroidism is a condition in which the thyroid gland does not make enough thyroid hormone.Iodine deficiency is the most common cause of hypothyroidism worldwide but it can be caused by other causes such as several conditions of the thyroid gland or, less commonly, the pituitary gland or...

, and goiter. There is also a risk of various other growth and developmental abnormalities.

Folic Acid

Folic acid
Folic acid
Folic acid and folate , as well as pteroyl-L-glutamic acid, pteroyl-L-glutamate, and pteroylmonoglutamic acid are forms of the water-soluble vitamin B9...

 (also known as folate) functions in reducing blood homosysteine levels, forming red blood cells, proper growth and division of cells, and preventing neural tube defects
Neural tube defects
Neural tube defects are one of the most common birth defects, occurring in approximately one in 1,000 live births in the United States. An NTD is an opening in the spinal cord or brain that occurs very early in human development. In the 2nd week of pregnancy called gastrulation, specialized cells...

 (NTDs).

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
Spina bifida
Spina bifida is a developmental congenital disorder caused by the incomplete closing of the embryonic neural tube. Some vertebrae overlying the spinal cord are not fully formed and remain unfused and open. If the opening is large enough, this allows a portion of the spinal cord to protrude through...

 and anencephaly
Anencephaly
Anencephaly is a cephalic disorder that results from a neural tube defect that occurs when the cephalic end of the neural tube fails to close, usually between the 23rd and 26th day of pregnancy, resulting in the absence of a major portion of the brain, skull, and scalp...

, 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
Folic acid
Folic acid and folate , as well as pteroyl-L-glutamic acid, pteroyl-L-glutamate, and pteroylmonoglutamic acid are forms of the water-soluble vitamin B9...

 by 72% .

The RDA
RDA
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 for folic acid
Folic acid
Folic acid and folate , as well as pteroyl-L-glutamic acid, pteroyl-L-glutamate, and pteroylmonoglutamic acid are forms of the water-soluble vitamin B9...

 ranges from as low as 150μg/day for children aged 1-3 years old, to 400μg/day for males and females over the age of 19, and 600μg/day during pregnancy.

Diseases associated with folic acid deficiency include: megaloblastic
Megaloblastic anemia
Megaloblastic anemia is an anemia that results from inhibition of DNA synthesis in red blood cell production. When DNA synthesis is impaired, the cell cycle cannot progress from the G2 growth stage to the mitosis stage...

 or macrocytic anemia, cardiovascular disease
Cardiovascular disease
Heart disease or cardiovascular disease are the class of diseases that involve the heart or blood vessels . While the term technically refers to any disease that affects the cardiovascular system , it is usually used to refer to those related to atherosclerosis...

, certain types of cancer, and NTDs in infants.

Niacin

Niacin
Niacin
"Niacin" redirects here. For the neo-fusion band, see Niacin .Niacin is an organic compound with the formula and, depending on the definition used, one of the forty to eighty essential human nutrients.Niacin is one of five vitamins associated with a pandemic deficiency disease: niacin deficiency...

 has been added to bread in the USA since 1938 (when voluntary addition started), a programme which substantially reduced the incidence of pellagra
Pellagra
Pellagra is a vitamin deficiency disease most commonly caused by a chronic lack of niacin in the diet. It can be caused by decreased intake of niacin or tryptophan, and possibly by excessive intake of leucine. It may also result from alterations in protein metabolism in disorders such as carcinoid...

. As early as 1755, pellegra was recognized by doctors as being a niacin deficiency disease. Although not officially receiving its name of pellegra until 1771. Pellagra
Pellagra
Pellagra is a vitamin deficiency disease most commonly caused by a chronic lack of niacin in the diet. It can be caused by decreased intake of niacin or tryptophan, and possibly by excessive intake of leucine. It may also result from alterations in protein metabolism in disorders such as carcinoid...

 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 and therefore was not contributing to the overall intake of niacin. Although pellegra can still be seen in developing countries, food fortification of this niacin played a huge role in eliminating the prevalence of the disease.

The RDA for niacin is 2mg NE(niacin equivalents)/day (AI) for infants aged 0-6 months, 16mg NE/day for males, and 14mg NE/day for females who are over the age of 19.

Diseases associated with niacin deficiency include: Pellegra which consisted of signs and symptoms called the 3D's-"Dermatitis, dementia, and diarrhea. Others may include vascular or gastrointestinal diseases.

Common diseases which present a high frequency of niacin deficiency: alcoholism, anorexia nervosa, HIV infection, gastrectomy, malabsorptive disorders, certain cancers and their associated treatments.

Vitamin D

Since Vitamin D
Vitamin D
Vitamin D is a group of fat-soluble secosteroids. In humans, vitamin D is unique both because it functions as a prohormone and because the body can synthesize it when sun exposure is adequate ....

 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. During the late 1800's, after the discovery of curing conditions of scurvy
Scurvy
Scurvy is a disease resulting from a deficiency of vitamin C, which is required for the synthesis of collagen in humans. The chemical name for vitamin C, ascorbic acid, is derived from the Latin name of scurvy, scorbutus, which also provides the adjective scorbutic...

 and beriberi
Beriberi
Beriberi is a nervous system ailment caused by a thiamine deficiency in the diet. Thiamine is involved in the breakdown of energy molecules such as glucose and is also found on the membranes of neurons...

 had occurred, researchers were aiming to see if the disease, later known as rickets
Rickets
Rickets is a softening of bones in children due to deficiency or impaired metabolism of vitamin D, magnesium , phosphorus or calcium, potentially leading to fractures and deformity. Rickets is among the most frequent childhood diseases in many developing countries...

, 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
Vitamin D
Vitamin D is a group of fat-soluble secosteroids. In humans, vitamin D is unique both because it functions as a prohormone and because the body can synthesize it when sun exposure is adequate ....

 was actually linked to curing rickets
Rickets
Rickets is a softening of bones in children due to deficiency or impaired metabolism of vitamin D, magnesium , phosphorus or calcium, potentially leading to fractures and deformity. Rickets is among the most frequent childhood diseases in many developing countries...

. 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.

Risk factors for vitamin D deficiencies include:
  • Infants who are exclusively or partially breast fed
  • Dark skinned people
  • People who live in colder climates and have little sun exposure
  • Elderly
  • Those who cover all parts of their skin while outdoors
  • Liberal use of SPF sunscreens
  • Fat malabsorption syndromes
  • Inflammatory bowel diseases
  • Obesity


The current RDA
RDA
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 for infants aged 0-6 months is 25mcg's (1000 International Units (IU)/day and for adults over 19 years of age it is 100mcg's (4000IU)/day.

Diseases associated with a vitamin D deficiency include rickets
Rickets
Rickets is a softening of bones in children due to deficiency or impaired metabolism of vitamin D, magnesium , phosphorus or calcium, potentially leading to fractures and deformity. Rickets is among the most frequent childhood diseases in many developing countries...

, osteoporosis
Osteoporosis
Osteoporosis is a disease of bones that leads to an increased risk of fracture. In osteoporosis the bone mineral density is reduced, bone microarchitecture is deteriorating, and the amount and variety of proteins in bone is altered...

, and certain types of cancer (breast, prostate, colon and ovaries). It has also been associated with increased risks for fractures, heart disease
Heart disease
Heart disease, cardiac disease or cardiopathy is an umbrella term for a variety of diseases affecting the heart. , it is the leading cause of death in the United States, England, Canada and Wales, accounting for 25.4% of the total deaths in the United States.-Types:-Coronary heart disease:Coronary...

, type 2 diabetes, autoimmune and infectious diseases, asthma
Asthma
Asthma is the common chronic inflammatory disease of the airways characterized by variable and recurring symptoms, reversible airflow obstruction, and bronchospasm. Symptoms include wheezing, coughing, chest tightness, and shortness of breath...

 and other wheezing disorders, myocardial infarction
Myocardial infarction
Myocardial infarction or acute myocardial infarction , commonly known as a heart attack, results from the interruption of blood supply to a part of the heart, causing heart cells to die...

, hypertension
Hypertension
Hypertension or high blood pressure is a cardiac chronic medical condition in which the systemic arterial blood pressure is elevated. What that means is that the heart is having to work harder than it should to pump the blood around the body. Blood pressure involves two measurements, systolic and...

, congestive heart failure
Congestive heart failure
Heart failure often called congestive heart failure is generally defined as the inability of the heart to supply sufficient blood flow to meet the needs of the body. Heart failure can cause a number of symptoms including shortness of breath, leg swelling, and exercise intolerance. The condition...

, and peripheral vascular disease.

Fluoride

Although fluoride
Fluoride
Fluoride is the anion F−, the reduced form of fluorine when as an ion and when bonded to another element. Both organofluorine compounds and inorganic fluorine containing compounds are called fluorides. Fluoride, like other halides, is a monovalent ion . Its compounds often have properties that are...

 is required in very small doses per day and not considered an essential mineral, it is seen as crucial in prevention of tooth decay and maintaining adequate dental health. In the mid 1900's it was discovered that towns with a high level of fluoride
Fluoride
Fluoride is the anion F−, the reduced form of fluorine when as an ion and when bonded to another element. Both organofluorine compounds and inorganic fluorine containing compounds are called fluorides. Fluoride, like other halides, is a monovalent ion . Its compounds often have properties that are...

 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
Fluoride
Fluoride is the anion F−, the reduced form of fluorine when as an ion and when bonded to another element. Both organofluorine compounds and inorganic fluorine containing compounds are called fluorides. Fluoride, like other halides, is a monovalent ion . Its compounds often have properties that are...

 with safe amounts to retain the properties of resistance to dental caries but avoid the staining cause by fluorosis
Fluorosis
Fluorosis can refer to:* Dental fluorosis* Skeletal fluorosisSkeletal fluorosis can be caused by: Cryolite ....

 (a condition caused by a fluoride toxicity).

The tolerable upper intake level (UL) set for fluoride ranges from 0.7mg/day for infants aged 0-6 months and 10mg/day for adults over the age of 19.

Conditions commonly associated with fluoride
Fluoride
Fluoride is the anion F−, the reduced form of fluorine when as an ion and when bonded to another element. Both organofluorine compounds and inorganic fluorine containing compounds are called fluorides. Fluoride, like other halides, is a monovalent ion . Its compounds often have properties that are...

 deficiency are dental caries and osteoporosis.

Others

Some other examples of fortified foods:
  • Calcium
    Calcium
    Calcium is the chemical element with the symbol Ca and atomic number 20. It has an atomic mass of 40.078 amu. Calcium is a soft gray alkaline earth metal, and is the fifth-most-abundant element by mass in the Earth's crust...

     is frequently added to fruit juices, carbonated beverages and rice.
  • White rice
    White rice
    White rice is the name given to milled rice that has had its husk, bran, and germ removed. This alters the flavour, texture and appearance of the rice and helps prevent spoilage and extend its storage life. After milling, the rice is polished, resulting in a seed with a bright, white, shiny...

     is frequently enriched to replace lost nutrients during milling or adding extras in.
  • "Golden rice
    Golden rice
    Golden rice is a variety of Oryza sativa rice produced through genetic engineering to biosynthesize beta-carotene, a precursor of pro-vitamin A in the edible parts of rice...

    " is a variety of rice which has been genetically modified
    Genetic engineering
    Genetic engineering, also called genetic modification, is the direct human manipulation of an organism's genome using modern DNA technology. It involves the introduction of foreign DNA or synthetic genes into the organism of interest...

     to produce beta carotene.
  • Amylase rich flour is utilized for food making to increase dietary consumption.

Fortification for body building

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.

Fortification for medical treatment

There is interest in the use of food supplements in established medical conditions. This nutritional supplementation using foods as medicine (nutraceutical
Nutraceutical
Nutraceutical, a portmanteau of the words “nutrition” and “pharmaceutical”, is a food or food product that reportedly provides health and medical benefits, including the prevention and treatment of disease. Health Canada defines the term as "a product isolated or purified from foods that is...

s) has been effectively used in treating disorders affecting the immune system up to and including cancers. This goes beyond the definition of "food supplement", but should be included for the sake of completeness.

See also

  • Food additive
    Food additive
    Food additives are substances added to food to preserve flavor or enhance its taste and appearance.Some additives have been used for centuries; for example, preserving food by pickling , salting, as with bacon, preserving sweets or using sulfur dioxide as in some wines...

  • Dietary supplement
    Dietary supplement
    A dietary supplement, also known as food supplement or nutritional supplement, is a preparation intended to supplement the diet and provide nutrients, such as vitamins, minerals, fiber, fatty acids, or amino acids, that may be missing or may not be consumed in sufficient quantities in a person's diet...

  • Food processing
    Food processing
    Food processing is the set of methods and techniques used to transform raw ingredients into food or to transform food into other forms for consumption by humans or animals either in the home or by the food processing industry...

  • Nutraceutical
    Nutraceutical
    Nutraceutical, a portmanteau of the words “nutrition” and “pharmaceutical”, is a food or food product that reportedly provides health and medical benefits, including the prevention and treatment of disease. Health Canada defines the term as "a product isolated or purified from foods that is...

  • Nutrification (aka food enrichment or fortification)
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