What is Fortification?

Fortification refers to the addition of nutrients to a commonly eaten food (the vehicle). It is possible for a single nutrient or group of micronutrients (the fortificant) to be added to the vehicle, which has been identified through a process in which all stakeholders have participated. This strategy is accepted as sustainable under most conditions and often is cost effective on a large scale when successfully implemented. Iron fortification of wheat flour and iodine fortification of salt is examples of fortification strategies with excellent results.

There are at least three essential conditions that must be met in any fortification programme: the fortificant (1) should be effective, bio-available, acceptable, and affordable; the selected food vehicle (2) should be easily accessible and a specified amount of it should be regularly consumed in the local diet; and detailed production instructions (3) and monitoring procedures should be in place and enforced by law.

References:
Lotfi, M., Venkatesh-Mannar, M.G., Merx, R.J.H.M. & P.Naber-van den Heuvel. 1996. Micronutrient Fortification of Foods. Current practices, research, and opportunities. Ottawa. The Micronutrient Initiative (MI), International Development Research Center (IDRC)/ International Agricultural Center (IAC).

Viteri, F.E. Prevention of Iron Deficiency. 1998. Chapter 3 In : Howson CP, Kennedy ET, Horwitz A (eds). Prevention of Micronutrient Deficiencies. Tools for Policymakers and Public Health Workers. p.45-102. National Academy Press, Washington, D.C.

Iron fortification

Food fortification with iron is recommended when dietary iron is insufficient or the dietary iron is of poor bio-availability, which is the reality for most people in the developing world and for vulnerable population groups in the developed world. Moreover, the prevalence of iron deficiency and anaemia in vegetarians and in populations of the developing world which rely on cereal or tuber foods is significantly higher than in omnivore populations.

Iron is present in foods in two forms, as heme iron, which is derived from flesh foods (meats, poultry, and fish), and as non-heme iron, which is the inorganic form present in plant foods such as legumes, grains, nuts, and vegetables. Heme iron is highly (20 - 30 percent) absorbed and its bio-availability is relatively unaffected by dietary factors. 

Non-heme iron has a lower rate of absorption (2–10 percent), depending on the balance between iron absorption inhibitors (phytates, polyphenols, calcium, and phosphate) and iron absorption enhancers (ascorbic and citric acids, cysteine-containing peptides, ethanol, and fermentation products) present in the diet. Because staple foods around the world provide predominantly non-heme iron sources of low bio-availability, the traditionally eaten staple foods represent an excellent vehicle for iron fortification. Examples of foods, which have been fortified, are wheat flour, corn (maize) flour, rice, salt, sugar, cookies, curry powder, fish sauce, and soy sauce. Nevertheless the beneficial effects of consumption of iron absorption enhancers have been extensively proven and should always be promoted (i.e., consumption of vitamin C–rich food together with the non-heme iron source).

References:
Hallberg, L., Hulthén, L. & Gramatkovski, E. 1997. Iron absorption from the whole diet in
men: how effective is the regulation of iron absorption? Am. J. Clin. Nutr., 66:347-56.

Allen, L.H. & Ahluwalia, N. 1997. Improving Iron Status Through Diet. The Application of
Knowledge Concerning Dietary Iron Bio-availability in Human Populations. Arlington, John Snow, Inc. Opportunities for Micronutrient Interventions Project.

Iodine fortification

Iodine is sparsely distributed in the Earth’s surface and foods grown in soils with little or no iodine lack an adequate amount of this micronutrient. This situation had made iodine

deficiency disorders exceedingly common in most of the world and highly prevalent in many countries before the introduction of salt iodisation. Only foods of marine origin are naturally rich sources of iodine. Salt is a common food used by most people worldwide, and the establishment of an well-implemented permanent salt-iodisation programme has been proven to eradicate iodine deficiency disorders. Universal salt iodisation is the best way to virtually eliminate iodine deficiency disorders.

However, salt iodisation is not simply a matter of legislating mandatory iodisation of salt. It is important to determine the best fortification technique, co-ordinate the implementation at all salt production sites, establish effective monitoring and quality control programmes, and measure iodine fortification level periodically. The difficulties in implementing salt iodisation programmes arise primarily when the salt industry is widely dispersed among many small producers. The level of iodine fortification usually lies between 25 and 50 mg/kg salt. The actual amount should be specified according to the level of salt intake and magnitude of deficit at the country level, because iodine must be added within safe and effective ranges. Additionally, it is very important to implement a monitoring plan to control the amount of iodine in the salt at the consumer’s table. United Nations agencies responsible for assisting governments in establishing iodisation programmes should provide technical support for programme implementation, monitoring, and evaluation to ensure sustainability.

References:
FAO/ILSI. 1997. Preventing Micronutrient Malnutrition: A Guide to Food-Based
Approaches, ILSI Press, Washington DC.

Stanbury, J.B. 1998. Prevention of Iodine Deficiency. Chapter 5 In: Howson CP, Kennedy
ET, Horwitz A (eds). Prevention of Micronutrient Deficiencies. Tools for Policymakers and
Public Health Workers. p.167-202. Washington, D.C., National Academy Press.

Unicef, ICCDD, PAMM, MNI, WHO. 1995. Monitoring Universal Salt Iodisation
Programmes. Sullivan, K.M., Houston, R., Gorstein, J., and J. Cervinskas, eds. Geneva.

Zinc fortification

The body depends on a regular zinc supply provided by the daily diet because stores are quite limited. Food diversity analysis demonstrates that it is virtually impossible to achieve zinc adequacy in the absence of a flesh food source. Among flesh foods, beef is the best source of zinc and is followed by poultry and then fish. Zinc fortification programmes are being studied, especially for populations, which consume predominately plant foods. Fortification of cereal staple foods is a potentially attractive intervention, which could benefit the whole population as well as target the vulnerable population groups of children and pregnant women. Such addition of zinc to the diet would perhaps decrease the prevalence of stunting in many developing countries with low-zinc diets, because linear growth is affected by zinc supply.

Folic acid fortification

The recommended nutrient density by the developers of the FAO/WHO (1) FBDGs for folic acid is 200 μg/4.184 MJ. Although this reference value is higher than other standards of reference, the increase in folic acid consumption by women of childbearing age is very important: it may improve birth weight and reduce the prevalence of neural tube defects by 50 percent. Elevated plasma homo-cysteine levels are considered to be an independent risk factor for heart disease; a higher intake of folic acid may also benefit the rest of the population because it may lower homo-cysteine levels in adults. In addition, folate may improve the mental condition of the elderly population.

Although the desirable folic acid density may be achieved through dietary diversity, it requires the daily presence of organ meats, green leafy vegetables, pulses, legumes, or nuts in the diet. Most population groups may not easily reach the appropriate level of folic acid consumption; therefore, folic acid fortification has been recommended. The United States initiated mandatory folic acid fortification of cereal-grain products in January 1998. The fortification level approved in the United States is 140 μg/100 g product, which will increase the average woman’s intake by only 100 μg/day. This amount is considered safe (a dose, which will not mask pernicious anaemia, which results from vitamin B12 deficiency,) but it may be ineffective in lowering the occurrence of neural tube defects.

References:
Tucker, K.L., Mahnken, B., Wilson, P.W.F., Jacques, P. & J. Selhub. 1996. Folic Acid Fortification of the Food Supply. Potential Benefits and Risk for the Elderly Population.
JAMA. 2776:1879-85.

Oakley, G.P., Adams, M.J. & Dickinson, Ch.M. 1996. More Folic Acid for Everyone, Now. Z J. Nutr., 126:751S-755S.

Bower, C. 1995. Folate and Neural Tube Defects. Nutr. Revs., 53 (9)II: S33-S38.

Daly, S., Mills, J.L., Molloy, A.M., Conley, M. Lee, Y.J., Kirke, P.N., Weir, D.G. & J.M. Scott. 1997. Minimum effective dose of folic acid for food fortification to prevent neural-tube defects. Lancet, 350:1666-69.