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Food fortification or enrichment is the process of adding
micronutrient Micronutrients are essential dietary elements required by organisms in varying quantities throughout life to orchestrate a range of physiological functions to maintain health. Micronutrient requirements differ between organisms; for example, huma ...
s (essential trace elements and vitamins) to
food Food is any substance consumed by an organism for nutritional support. Food is usually of plant, animal, or fungal origin, and contains essential nutrients, such as carbohydrates, fats, proteins, vitamins, or minerals. The substance is in ...
. It can be carried out by food manufacturers, or by governments as a
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". Analyzing the det ...
policy which aims to reduce the number of people with dietary deficiencies within a population. The predominant diet within a region can lack particular nutrients due to the local soil or from inherent deficiencies within the staple foods; the addition of micronutrients to staples and condiments can prevent large-scale deficiency diseases in these cases. As defined by the
World Health Organization The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level o ...
(WHO) and the
Food and Agricultural Organization of the United Nations The Food and Agriculture Organization of the United Nations (FAO)french: link=no, Organisation des Nations unies pour l'alimentation et l'agriculture; it, Organizzazione delle Nazioni Unite per l'Alimentazione e l'Agricoltura is an intern ...
(FAO), fortification refers to "the practice of deliberately increasing the content of an essential micronutrient, i.e. vitamins and minerals (including trace elements) in a food, 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".World Health Organization and Food and Agriculture Organization of the United Nations Guidelines on food fortification with micronutrients.
2006 ited on 2011 Oct 30
Food fortification has been 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 commonly fortified foods are
cereal A cereal is any grass cultivated for the edible components of its grain (botanically, a type of fruit called a caryopsis), composed of the endosperm, germ, and bran. Cereal grain crops are grown in greater quantities and provide more food ...
s and cereal-based products;
milk Milk is a white liquid food produced by the mammary glands of mammals. It is the primary source of nutrition for young mammals (including breastfed human infants) before they are able to digest solid food. Immune factors and immune-modulat ...
and dairy products; fats and oils; accessory food items; tea and other beverages; and
infant formula Infant formula, baby formula, or simply formula (American English); or baby milk, infant milk or first milk (British English), is a manufactured food designed and marketed for feeding to babies and infants under 12 months of age, usually prepar ...
s. Undernutrition and nutrient deficiency is estimated globally to cause the deaths of between 3 and 5 million people per year.


Types

Fortification is present in common food items in two different ways: adding back and addition. Flour loses nutritional value due to the way grains are processed; Enriched Flour has iron, folic acid, niacin, riboflavin, and thiamine added back to it. Conversely, other fortified foods have micronutrients added to them that don't naturally occur in those substances. An example of this is orange juice, which often is sold with added
calcium Calcium is a chemical element with the symbol Ca and atomic number 20. As an alkaline earth metal, calcium is a reactive metal that forms a dark oxide-nitride layer when exposed to air. Its physical and chemical properties are most similar ...
. Food fortification can also be categorized according to the stage of addition: # Commercial and industrial fortification (wheat flour, corn meal, cooking oils) # Biofortification (breeding crops to increase their nutritional value, which can include both conventional selective breeding, and genetic engineering) # Home fortification (example: vitamin D drops)


Rationale

Micronutrient Micronutrients are essential dietary elements required by organisms in varying quantities throughout life to orchestrate a range of physiological functions to maintain health. Micronutrient requirements differ between organisms; for example, huma ...
s serve an important role in bodily development and growth. Deficiencies of these micronutrients may cause improper development or even disease. The WHO and FAO, among many other nationally recognized organizations, have recognized that there are over 2 billion people worldwide who have 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 their associated health conditions. In Canada, the Food and Drug Regulations have outlined specific criteria which justify food fortification: # To replace nutrients which were lost during manufacturing of the product (e.g. the manufacturing of flour) # To act as a
public health intervention A public health intervention is any effort or policy that attempts to improve mental and physical health on a population level. Public health interventions may be run by a variety of organizations, including governmental health departments and ...
# To ensure the nutritional equivalence of substitute foods (e.g. 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 (e.g., 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 regularly.


Around the world

The subsections below describe fortifications in some jurisdictions around the world. A more comprehensive view is given by the online ''Global Fortification Data Exchange.'' It indicates which of 197 countries worldwide have mandatory and voluntary food fortification in their datasets and country profiles. The website is maintained by the ''Food Fortification Initiative'',
GAIN Gain or GAIN may refer to: Science and technology * Gain (electronics), an electronics and signal processing term * Antenna gain * Gain (laser), the amplification involved in laser emission * Gain (projection screens) * Information gain in de ...
,
Iodine Global Network The Iodine Global Network (abbreviated IGN; formerly the International Council for the Control of Iodine Deficiency Disorders Global Network or ICCIDD Global Network) describes itself as a "non-profit, non-government organization for the sustainabl ...
, and the ''Micronutrient Forum''.


Argentina

In
Argentina Argentina (), officially the Argentine Republic ( es, link=no, República Argentina), is a country in the southern half of South America. Argentina covers an area of , making it the List of South American countries by area, second-largest ...
, wheat flour must by law (''Ley 25.630'' of 2002) be fortified with iron, thiamine (vitamin B1), riboflavin (B2), niacin (B3), and folic acid (B9).


Colombia

Wheat flour sold in
Colombia Colombia (, ; ), officially the Republic of Colombia, is a country in South America with insular regions in North America—near Nicaragua's Caribbean coast—as well as in the Pacific Ocean. The Colombian mainland is bordered by the ...
must by law be fortified with vitamin B1, vitamin B2, niacin (B3), folic acid (B9) and iron (''Decreto 1944'' of 1996).


El Salvador, Guatemala, Honduras and Nicaragua

The four countries, also called the C-4, all legally require wheat flour to be fortified with vitamins B1, B2, B3, B9, and iron.


Philippines

The
Philippine The Philippines (; fil, Pilipinas, links=no), officially the Republic of the Philippines ( fil, Republika ng Pilipinas, links=no), * bik, Republika kan Filipinas * ceb, Republika sa Pilipinas * cbk, República de Filipinas * hil, Republ ...
law on food fortification has two components: mandatory (covering select staples) and voluntary (under the ''Sangkap Pinoy'' program). The latter has been criticized for covering only low nutritional-value food, namely,
junk food "Junk food" is a term used to describe food that is high in calories from sugar and/or fat, and possibly also sodium, but with little dietary fiber, protein, vitamins, minerals, or other important forms of nutritional value. It is also known ...
, to enable them to be sold in schools.


United Kingdom

UK law (The Bread and Flour Regulations 1998) requires that all flour (except wholemeal and some self-raising flours) be fortified with
calcium Calcium is a chemical element with the symbol Ca and atomic number 20. As an alkaline earth metal, calcium is a reactive metal that forms a dark oxide-nitride layer when exposed to air. Its physical and chemical properties are most similar ...
. Wheat flour must also be fortified with iron, thiamine (vitamin B1) and vitamin B3.


United States

In the 1920s, food fortification emerged as a strategy in the United States to address and prevent the lack of micronutrients in the population's diet.  Specifically, it was discovered in the 1930s and 1940s, that micronutrient deficiency is often linked to specific diseases and syndromes. Consequently, The Committee on Food and Nutrition suggested that micronutrients be added to flour. In 1980, The Food and Drug Administration put into action its Food Fortification Policy which included six fundamental rules. In addition to establishing safety guidelines of food fortification, this policy aimed to ensure that food fortification was solely for when the supplemental micronutrient had a national deficiency and that the food chosen to provide that nutrient was consumed by enough of the population to make a change. This policy also emphasized the importance of clinical data, a shift from earlier policies which relied on dietary data alone. The 2002 farm bill (P.L. 107–171, Sec. 3013) requires the
Administrator of USAID The administrator of the United States Agency for International Development is the head of the United States federal government's Agency for International Development (USAID). The administrator is officially nominated by the President of the ...
, in consultation with the
Secretary of Agriculture The United States secretary of agriculture is the head of the United States Department of Agriculture. The position carries similar responsibilities to those of agriculture ministers in other governments. The department includes several organi ...
, to establish micronutrient fortification programs under P.L. 480 food aid. Section 3013 replaces a pilot program similarly named and authorized in the 1996 farm bill (P.L. 104–127, Sec. 415). Under the programs, grains and other commodities made available to countries selected for participation will be fortified with micronutrients (e.g., iron, vitamin A, iodine, and
folic acid Folate, also known as vitamin B9 and folacin, is one of the B vitamins. Manufactured folic acid, which is converted into folate by the body, is used as a dietary supplement and in food fortification as it is more stable during processing a ...
).


Criticism

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 among 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. In addition to criticism of government-mandated fortification, food companies have been criticized for indiscriminate enrichment of foods for marketing purposes. Food safety worries led to legislation in
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in 2004 restricting foods fortified with extra vitamins or minerals. Products banned include: Rice Krispies,
Shreddies Shreddies are a breakfast cereal first produced in Canada in 1939 by Nabisco. The ''Shreddies'' brand is held by Post Consumer Brands in Canada and elsewhere, and Nestlé in Ireland and the United Kingdom. Manufacture In Canada, production beg ...
, Horlicks,
Ovaltine Ovaltine (also known by its original name Ovomaltine) is a brand of milk flavoring product made with malt extract (except in the blue packaging in the United States), sugar (except in Switzerland), and whey. Some flavors also have cocoa. Ovalt ...
and Marmite.


Limited absorption

One factor that limits the benefits of food fortification is that isolated nutrients added back into 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 Vitamin D is a group of Lipophilicity, fat-soluble secosteroids responsible for increasing intestinal absorption of calcium, magnesium, and phosphate, and many other biological effects. In humans, the most important compounds in this group ar ...
added back. Vitamins A and D are both fat-soluble and non-water-soluble, so a person consuming skim milk without fats may not be able to absorb as much of these vitamins as one would be able to absorb from drinking whole milk. On the other hand, the nutrient added as a fortificant may have a higher bioavailability than from foods, which is the case with folic acid used to increase folate intakes. Phytochemicals such as
phytic acid Phytic acid is a six-fold dihydrogenphosphate ester of inositol (specifically, of the ''myo'' isomer), also called inositol hexakisphosphate (IP6) or inositol polyphosphate. At physiological pH, the phosphates are partially ionized, resulting ...
in cereal grains can also impact nutrient absorption, limiting the bioavailability of intrinsic and additional nutrients, and reducing the effectiveness of fortification programs.


Different forms of micronutrients

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.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.
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. 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 Retinol, also called vitamin A1, is a fat-soluble vitamin in the vitamin A family found in food and used as a dietary supplement. As a supplement it is used to treat and prevent vitamin A deficiency, especially that which results in xeroph ...
, the active form of Vitamin A, is toxic in a much lower dose than other forms, such as beta carotene. Menadione, a phased-out synthetic form of
Vitamin K Vitamin K refers to structurally similar, fat-soluble vitamers found in foods and marketed as dietary supplements. The human body requires vitamin K for post-synthesis modification of certain proteins that are required for blood coagulation ...
, is also known to be toxic.


Examples of fortification in 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. 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 there will be a market to support the change. The Food Fortification Initiative lists all countries in the world that conduct fortification programs, and within each country, what nutrients are added to which foods, and whether those programs are voluntary or mandatory. Vitamin fortification programs exist in one or more countries for folate, niacin, riboflavin, thiamine, vitamin A, vitamin B6, vitamin B12, vitamin D and vitamin E. Mineral fortification programs include calcium, fluoride, iodine, iron, selenium and zinc. As of December 21, 2018, 81 countries required food fortification with one or more vitamins. The most commonly fortified vitamin – as used in 62 countries – is folate; the most commonly fortified food is wheat flour ( enriched flour). Examples of foods and beverages that have been fortified:


Iodized salt

Iodised salt has been used in the
United States The United States of America (U.S.A. or USA), commonly known as the United States (U.S. or US) or America, is a country Continental United States, primarily located in North America. It consists of 50 U.S. state, states, a Washington, D.C., ...
since before
World War II World War II or the Second World War, often abbreviated as WWII or WW2, was a world war that lasted from 1939 to 1945. It involved the World War II by country, vast majority of the world's countries—including all of the great power ...
. 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 for iodine is as low as 90 µg/day for children (4–8 years) and as high as 290 µg/day for breast-feeding mothers. Diseases that are associated with an iodine deficiency include:
intellectual disabilities Intellectual disability (ID), also known as general learning disability in the United Kingdom and formerly mental retardation,Rosa's Law, Pub. L. 111-256124 Stat. 2643(2010). is a generalized neurodevelopmental disorder characterized by signifi ...
,
hypothyroidism Hypothyroidism (also called ''underactive thyroid'', ''low thyroid'' or ''hypothyreosis'') is a disorder of the endocrine system in which the thyroid gland does not produce enough thyroid hormone. It can cause a number of symptoms, such as ...
, and goiter. There is also a risk of various other growth and developmental abnormalities.


Folate

Folate (as a fortification ingredient, folic acid) functions in reducing blood homocysteine levels, forming red blood cells, proper growth and division of cells and preventing neural tube defects (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 and
anencephaly Anencephaly is the absence of a major portion of the brain, skull, and scalp that occurs during embryonic development. It is a cephalic disorder that results from a neural tube defect that occurs when the rostral (head) end of the neural tube ...
, 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 Folate, also known as vitamin B9 and folacin, is one of the B vitamins. Manufactured folic acid, which is converted into folate by the body, is used as a dietary supplement and in food fortification as it is more stable during processing a ...
by 72%.


Niacin

Niacin Niacin, also known as nicotinic acid, is an organic compound and a form of vitamin B3, an essential human nutrient. It can be manufactured by plants and animals from the amino acid tryptophan. Niacin is obtained in the diet from a variet ...
(a form of vitamin B3) has been added to bread in the US since 1938 (when voluntary addition started), a program which substantially reduced the incidence of pellagra. 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. Diseases associated with niacin deficiency include pellagra which consisted of signs and symptoms called the three D's-"dermatitis, dementia, and diarrhea." Others may include vascular or gastrointestinal diseases. Common diseases which present a high frequency of niacin deficiency include alcoholism, anorexia nervosa, HIV infection, gastrectomy, malabsorptive disorders, certain cancers and their associated treatments.


Vitamin D

Since
Vitamin D Vitamin D is a group of Lipophilicity, fat-soluble secosteroids responsible for increasing intestinal absorption of calcium, magnesium, and phosphate, and many other biological effects. In humans, the most important compounds in this group ar ...
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 1800s, after the discovery of curing conditions of
scurvy Scurvy is a deficiency disease, disease resulting from a lack of vitamin C (ascorbic acid). Early symptoms of deficiency include weakness, feeling tired and sore arms and legs. Without treatment, anemia, decreased red blood cells, gum disease, ch ...
and
beriberi Thiamine deficiency is a medical condition of low levels of thiamine (Vitamin B1). A severe and chronic form is known as beriberi. The two main types in adults are wet beriberi and dry beriberi. Wet beriberi affects the cardiovascular system, r ...
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 Vitamin D is a group of Lipophilicity, fat-soluble secosteroids responsible for increasing intestinal absorption of calcium, magnesium, and phosphate, and many other biological effects. In humans, the most important compounds in this group ar ...
was actually linked to curing rickets. 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. 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 Type 2 diabetes, formerly known as adult-onset diabetes, is a form of diabetes mellitus that is characterized by high blood sugar, insulin resistance, and relative lack of insulin. Common symptoms include increased thirst, frequent urinatio ...
, autoimmune and infectious diseases,
asthma Asthma is a long-term inflammatory disease of the airways of the lungs. It is characterized by variable and recurring symptoms, reversible airflow obstruction, and easily triggered bronchospasms. Symptoms include episodes of wheezing, co ...
and other wheezing disorders,
myocardial infarction A myocardial infarction (MI), commonly known as a heart attack, occurs when blood flow decreases or stops to the coronary artery of the heart, causing damage to the heart muscle. The most common symptom is chest pain or discomfort which ma ...
,
hypertension Hypertension (HTN or HT), also known as high blood pressure (HBP), is a long-term medical condition in which the blood pressure in the arteries is persistently elevated. High blood pressure usually does not cause symptoms. Long-term high b ...
,
congestive heart failure Heart failure (HF), also known as congestive heart failure (CHF), is a syndrome, a group of signs and symptoms caused by an impairment of the heart's blood pumping function. Symptoms typically include shortness of breath, excessive fatigue, ...
, and peripheral vascular disease.


Fluoride

Although fluoride is not considered an essential mineral, it is useful in prevention of tooth decay and maintaining adequate dental health. 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 in safe amounts (or reduction of naturally occurring levels) to retain the properties of resistance to dental caries but avoid the staining caused by fluorosis (a condition caused by excessive fluoride intake). 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.


See also

* Food additive * Food composition *
Dietary supplement A dietary supplement is a manufactured product intended to supplement one's diet by taking a pill, capsule, tablet, powder, or liquid. A supplement can provide nutrients either extracted from food sources or that are synthetic in order ...
*
Food processing Food processing is the transformation of agricultural products into food, or of one form of food into other forms. Food processing includes many forms of processing foods, from grinding grain to make raw flour to home cooking to complex in ...
* Nutraceutical


External links


Food fortification in the Philippines: Policies, programmes, issues, and prospects


References

{{DEFAULTSORT:Food Fortification Food additives