- Email: [email protected]
Food Fortification
Food Fortification MG Venkatesh Mannar, University of Toronto, Toronto, ON, Canada Annie S Wesley, International Development Research Centre, Ottawa, ON, Canada Ó 2017 Elsevier Inc. All rights reserved.
Introduction
consume, as widely documented (UNICEF, 2015; WHO/FAO, 2006), mainly staple foods, and hence, those foods need to provide a critical amount of micronutrients to prevent large population segments from developing or worsening micronutrient deficiencies. The potential contribution of large-scale fortification of staple foods and condiments toward filling the micronutrient intake gap cannot be ignored. The Lancet (2008 and 2013) Maternal and Child Nutrition Series, the Copenhagen Consensus, and Scaling Up Nutrition (SUN) Movement all recognize and endorse staple food fortification as a sustainable, cost-effective intervention with a proven impact on public health and economic development. Reducing micronutrient deficiencies and undernutrition has the potential to reduce by more than half the global burden of disability for children under age 5, to prevent more than one-third of global child deaths per year, and, in Asia and Africa, to boost GDP by up to 11%.
Relative contribution of interventions to eliminate micronutrient deficiencies
The human body requires minute quantities of vitamins and minerals, known as micronutrients, for growth, brain development, and immunity against diseases. Since the body cannot synthesize these nutrients, they need to be supplied through the diet or other external sources. When the intake or absorption of essential vitamins and minerals from the diet is inadequate (commonly referred to as ‘hidden hunger’), individuals and communities suffer serious consequences, including learning disabilities, impaired work capacity, illness, and death. This is exacerbated by the fact that commonly consumed plant-based diets and beverages such as tea and coffee are high in inhibitors and low in enhancers of micronutrient absorption. Micronutrient deficiencies can be effectively prevented and even eliminated if populations consume adequate quantities of the bioavailable forms of required vitamins and minerals on a continuous and ongoing basis. There is no single solution to combat the ‘hidden hunger.’ However, years of program experience identified several solutions which are not mutually exclusive but complement one another. The solutions include ingestion of oral supplements (tablets, capsules, and syrups), public health measures, food fortification, and other foodbased approaches. Figure 1 illustrates how these approaches could relate over time: for example, supplementation with high doses of micronutrients is a short-term measure to address a severe deficiency, and its use is envisaged to come down as the longer-term measures are established. Food fortification is a medium- to long-term solution to alleviate specific nutrient deficiencies in a population. It involves addition of measured amounts of a nutrient-rich ‘premix’ containing the required vitamins and minerals to commonly eaten foods during processing. During moments of economic crisis, populations with lower purchasing power
Concept and Application According to Codex Alimentarius (a collection of internationally accepted food standards, codes of practice, and guidelines), 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. Food fortification involves the identification of commonly eaten foods that are centrally processed so that fortification could be dovetailed into the food production and distribution systems. This also means that fortification within the existing food patterns does not change the dietary practices of the population and so does not require special individual compliance. Staple foods and condiments are the obvious choice for
Supplementation Public health measures
Fortification
Dietary improvement
Time Figure 1
Complementary micronutrient interventions.
International Encyclopedia of Public Health, 2nd edition, Volume 3
http://dx.doi.org/10.1016/B978-0-12-803678-5.00160-0
143
144
Food Fortification
fortification given their consistent consumption by large sections of the population. In most developing countries the choice of vehicles is limited to a handful of staple foods and condiments: cereals, oils and fats, sugar, salt, and sauces. The vitamins and minerals used for fortification typically include vitamins A, D, folic acid and other B-complex vitamins, iodine, iron, and zinc. There is, however, no one single model appropriate for all population segments, making it imperative to design and implement complementary approaches to ensure the greatest penetration of fortified food products. There are also specific situations where large-scale food fortification can be enhanced by targeted fortification to reach vulnerable population subgroups, such as home fortification for vulnerable families, complementary foods for infants and young children (micronutrient powders, lipid-based nutrient supplements, fortified blended foods, etc.), and special foods for older children and pregnant and lactating women (biscuits, yogurt, beverages, etc.) (Moench-Pfanner et al., 2012). While the addition of nutrients to foods can help maintain and improve the overall nutritional quality of diets, indiscriminate fortification of foods could result in overfortification or underfortification in the food supply and nutrient imbalances in the diets of individuals. Any changes in food fortification policy for micronutrients must be considered within the context of the impact they will have on all segments of the population and of food technology and safety applications and their limitations (Dwyer et al., 2015). The start-up cost for food fortification is relatively inexpensive for the food industry, and recurrent costs are rapidly passed on to the consumer. The benefits of fortification can extend over the entire life cycle of humans. It can thus be one of the most cost-effective means of overcoming micronutrient malnutrition. The economics of food fortification has played an important role in its implementation in public policy. Food fortification is not a new concept. Addition of nutrients to staple foods was introduced nearly 70 years back as a means of dealing with micronutrient deficiencies prevalent in Europe and North America. In industrialized countries, several nutritional deficiencies have been eliminated partly because of a normally varied and rich diet and partly because most such nations have for decades been fortifying widely consumed foods such as flour, salt, juices, margarine, milk, and sugar.
Food Vehicles Common food vehicles that can be fortified include wheat and wheat products, corn, rice, milk and milk products, cooking oils, salt, sugar, breakfast cereals, and condiments. As processed foods gain popularity and market reach in the developing world, they offer new channels for micronutrient delivery. Potential food vehicles can be presented as a three-tiered pyramid (Figure 2). Staple foods at the base of the pyramid are cost-effective to fortify on a mass scale. Basic foods such as breads and biscuits, packaged cereals and flours, and dairy products are in the middle; and value-added foods such as condiments, snacks, candies, convenience and ready-to-eat foods are at the top. Fortifying less expensive staple foods at the base of the pyramid results in broader dissemination of micronutrients throughout the population, particularly to the poor. Also, fortifying foods at the base of the pyramid has a better chance of fortifying products through the other tiers of the pyramid because staple foods are generally used to produce basic and value-added foods. Table 1 provides examples of typical food vehicles and nutrients added. Each food vehicle offers specific opportunities and constraints: Cereals: Staples such as rice, corn, and wheat that are milled at centralized locations have the potential to reach large populations and are used in several countries as vehicles for multiple nutrients. When staple cereals are milled at the community level, it poses a challenge because of quality and safety constraints. For fortifying whole grain cereals such as rice, there is now a technology to produce simulated riceshaped premix. Fats and oils: Cooking fats and oils offer an option to deliver fat soluble vitamins such as vitamins A and D. While they have an advantage in that they are often centrally refined and packed, there is still the challenge of a large proportion being sold in loose unbranded form. Packaging in opaque containers is critical to protect the vitamins from degradation.
Value-added foods e.g., condiments, beverages, convenience foods, candies
Planning and Implementation When a country or region is ready to implement food fortification, the process begins by identifying the commonly eaten foods that can act as vehicles for one or more micronutrients. Food fortification aims to provide meaningful levels of the nutrient (usually 30–50% of the daily adult requirements) at normal consumption of the food vehicle. The levels also need to take into account variations in food consumption so that the safety of those at the higher end of the scale and impact for those at the lower end are ensured. They should also consider prorated intakes by young children to ensure efficacious and safe dosages. Cost, bioavailability, sensory acceptability, and storage stability are some of the criteria that determine the best match between the nutrient and food vehicle.
Basic foods e.g., breads, biscuits, packaged cereals, dairy products
Staple foods e.g., whole grain and milled cereals, oils and fats, sugar, salt
Figure 2
Food product pyramid.
Food Fortification
Table 1
Examples of foods for fortification
Food vehicle
Nutrients
Salt Wheat and maize flours Rice Cooking oils and fats Sugar Condiments (sauces) Milk Complementary foods
Iodine (and iron) Iron, folic acid, vitamin A, and B vitamins Iron, vitamin A, and B vitamins Vitamins A and D Vitamin A Iron Vitamins A and D; iron Multiple vitamins and minerals
Condiments: Salt, sugar, spices, and sauces are attractive carriers. Some are processed centrally and consumed in regular quantities and offer great potential. Recent studies show the promise for salt double fortified with iron and iodine. Dairy products: In areas where milk is processed in dairies, this may offer an option for fortification with both vitamins and minerals. Value-added products: Given the global demographic shifts from rural to urban areas, a larger proportion of the population can now be reached via commercially processed foods and value-added products. However, the most vulnerable populations consume these higher priced products (such as snack foods or beverage drinks) only sporadically. A multifaceted approach of fortifying more than one food vehicle is a good strategy, especially when a universally consumed vehicle is not available. When multiple foods are fortified, each with less than the Estimated Average Requirements (EAR) per single serving, the possibility of consuming toxic levels of a micronutrient through excess consumption of a single food becomes more remote.
145
Europe. They are available to children through a Special Supplemental Nutrition Program for Women, Infants and Children (WIC) in the United States. Programs that supply fortified complementary foods to infants and young children have also been introduced in several developing countries (Lutter and Dewey, 2003). Where there are few centrally processed complementary foods, alternative mechanisms include home fortification where micronutrient mixes in daily dose sachets have been successful (Schauer and Zlotkin, 2003). Market-driven fortification: When food manufacturers take a business-oriented approach to fortify some of the products as value-added products complying with the specifications for permissible nutrients and quantities. Mass and targeted fortification programs would focus on those micronutrients that are in the greatest need by the general population. Cost becomes a factor and it is important to have the collaboration of different stakeholders, particularly those in government and the milling industries. On the other hand, market-driven fortification might lean toward those micronutrients that have the greatest recognition and appeal to the intended market, usually the higher socioeconomic group that would purchase the premium products. Cost is generally not an issue in this situation. Mandatory versus voluntary fortification: Based on compliance requirements, food fortification can be mandatory or voluntary. In mandatory fortification it is stipulated by a country’s law that certain foods should be fortified with specified nutrients and levels. On the other hand, in voluntary fortification the food industry is permitted to add micronutrients as long as it is within a framework of specifications. Mass fortification is generally mandatory; targeted fortification can either be mandatory or voluntary whereas market-driven fortification is voluntary.
Reach of Fortified Foods Based on the population that would benefit from the fortified food and the type of industry compliance, several types of fortification are described in the Guidelines on Food Fortification with Micronutrients (WHO/FAO, 2006). Mass fortification: When foods widely consumed by the general population are fortified where the population has an unacceptable public health risk of being or becoming deficient in specific micronutrients. Flour fortification with iron and folic acid is a good example. Targeted fortification: When fortification is aimed at specific subgroups of the population, thereby increasing the intake of that particular group rather than that of the population as a whole. Examples include complementary foods for young children or food rations for displaced populations. Complementary foods and home fortification: Among the targeted fortification, complementary foods need special mention. Infants and children under the age of 24 months have a different dietary pattern than adults. Industrially produced fortified complementary foods are recommended by pediatricians as an essential part of an infant’s diet beyond the age of 6 months complementary to breast milk and homemade foods. Fortified infant formulas and cereals are commonly fed to young children in North America and
Technology The actual mechanics of adding the nutrients to the food is technically simple. Technology of food fortification also considers cost, bioavailability, sensory acceptability, and storage stability. Some technical considerations in planning a food fortification program include: l
l l
l l
The food used as a vehicle should be consumed in fairly constant amounts so that fortification levels can be accurately calculated. To do this, it is important to understand the consumption patterns of the food vehicle across the country. If it is for targeted fortification, the consumption pattern of the specific target group is needed. The chosen food should be processed centrally in large enough units to permit controlled fortification. The addition of the micronutrients should be compatible within existing food production and distribution systems. There should be minimum loss of the nutrient during processing, storage, and final preparation of the food. There should be no change in taste, appearance, or color of the final product. The food should be affordable so that the low-income groups, which are more vulnerable to malnutrition, consume it.
146
Food Fortification
Depending on the food processing methods, the addition of the micronutrients can be facilitated using different approaches to maximize the nutrient retention: l
l l l l
l l
l
l
Dry mixing – for cereal flours, powder milk, powder beverages. This is one of the common mechanisms used for the addition of the nutrient premix to the food. Dissolution in water – for liquid milk, drinks, fruit juices, and in the water used for making bread, pasta, and cookies. Dissolution in oil – for the lipid-soluble vitamins for enrichment of oily products such as margarine. Spraying – as in iodization of salt and in corn flakes where the nutrients do not withstand the cooking or extrusion step. Adhesion – as in sugar fortification where the vitamin A in powder form is adhered to the surface of the sugar crystal by vegetable oil. Coating – as in rice where the vitamins are sprayed over the grain as a coating. Extrusion and dry mixing – simulated rice-shaped premix of micronutrients is produced through an extrusion process and dry mixed with regular rice. Encapsulation – as in double fortification of salt where iron compound is encapsulated in order to prevent interaction with iodine and the food matrix. Micronization – as in salt fortification where the particle size of an iron compound is reduced in order to increase its bioavailability.
Figure 3 depicts a simplified framework of how fortification of cereal flour takes place.
Selection of Nutrient Form The chemical form of the nutrients being added (fortificants) influences the bioavailability, chemical stability, appearance, and homogeneity of the fortified food product. Vitamins and minerals
Blended to make a premix
Added to foods during milling
The choice depends, in part, on its solubility in the gastric juice and also on its impact on sensory characteristics of the food itself. Iron compounds used as fortificants provide the best examples to explain this concept. The iron compounds may be classified as (1) soluble in water, (2) slightly soluble in water and highly soluble in dilute acid as in gastric juice, (3) insoluble in water and poorly soluble in dilute acid, and (4) chelated iron compounds. Highly water-soluble compounds such as ferrous sulfate have excellent bioavailability and are suitable for a variety of applications but could create problems of unacceptable taste and color in the presence of high moisture and lipid contents. In such situations less soluble forms of iron are chosen to ensure consumer acceptance. Due to its high bioavailability, use of sodium iron EDTA (chelated iron) is recognized more recently as the fortificant of choice for soy sauce, fish sauce, and whole wheat/maize flours. Table 1 summarizes the selection of iron compounds to fortify commonly used foods. Though not as extensive as in iron, similar choices are available for other nutrients also. The Guidelines on Food Fortification with Micronutrients provides a comprehensive overview on the choice of the nutrients for fortification (WHO/FAO, 2006). Research and development efforts have enhanced effectiveness of fortification technology. In the case of Vitamin A, work is ongoing to reduce loss of nutrient potency on storage through addition of antioxidants and other stabilizers. Better refining procedures and packaging have significantly improved the stability of iodine compounds in salt and vitamin A in cooking oils. In the case of iron, stabilizers and absorption enhancers could be added along with the fortificant to retain it in an absorbable form or improve absorption. The structure of the iron compounds can also been modified to improve absorption (Table 2).
In accordance with government regulations and technical specifications
Staple grains grown by the farmer
Fortified flour
The fortified flour is eaten as baked or cooked products resulting in healthier individuals and families
Figure 3
Schematic diagram of cereal flour fortification.
Food Fortification
Table 2
147
WHO recommendations for average micronutrient fortification levels Fortification level (ppm) according to flour consumption (g day 1)
Micronutrient
Flour extraction rate
Compound
<75 g day
Iron
Low
Folic acid Vitamin B12 Vitamin A Zinc
High Low or high Low or high Low or high Low High
NaFeEDTA Ferrous sulfate Ferrous fumarate Electrolytic iron NaFeEDTA Folic acid Cyanocobalamin Vitamin A palmitate Zinc oxide Zinc oxide
40 60 60 NR 40 5.0 0.04 5.9 95 100
1
75–149 g day 40 60 60 NR 40 2.6 0.02 3 55 100
1
150–300 g day 20 30 30 60 20 1.3 0.01 1.5 40 80
1
>300 g day
1
15 20 20 40 15 1.0 0.008 1 30 70
Source: Adapted from Hurrell, R., Ranum, P., de Pee, S., Biebinger, R., Hulthen, L., Johnson, Q., Lynch, S., 2010. Revised recommendations for iron fortification of wheat flour and an evaluation of the expected impact of current national wheat flour fortification programs. Food Nutr. Bull. 31, S7–S21.
Implementation
regulations provide legal authority and an adequate regulatory framework. Effective regulatory controls through established fortification standards protect consumers against the risk of purchasing and consuming nutritionally inadequate, deceptively mislabeled or misbranded, impure or unsafe foods. Regulations also create a ‘level playing field’ for food manufacturers and sellers.
When a country or region is ready to implement food fortification, the process begins by identifying the commonly eaten foods that can act as vehicles for one or more micronutrients. Food fortification aims to provide meaningful levels of the nutrient (usually 30–50% of the daily adult requirements) at normal consumption of the food vehicle. The levels also need to take into account variations in food consumption so that the safety of those at the higher end of the scale and impact for those at the lower end are ensured. They should also consider prorated intakes by young children to ensure efficacious and safe dosages. Cost, bioavailability, sensory acceptability, and storage stability are some of the criteria that determine the best match between the nutrient and food vehicle.
Quality Assurance
Economics
Partnerships
The start-up cost for food fortification is relatively inexpensive for the food industry, and recurrent costs are rapidly passed on to the consumer. The benefits of fortification can extend over the entire life cycle of humans. It can thus be one of the most cost-effective means of overcoming micronutrient malnutrition. The economics of food fortification has played an important role in its implementation in public policy. Premix is the single greatest expense in fortification programs, accounting for up to 70–90% of recurring fortification costs (Griffiths, 2003). In higher-income industrialized countries, such costs are generally absorbed into the consumer price of the fortified food. However, this is not always the case for lower-income countries. Millers operate on thin profit margins in risky business environments, and poor consumers are highly price sensitive and cannot necessarily absorb the additional costs of premix. As a result, in many instances, premix costs can be a serious deterrent to private sector involvement and compliance in fortification programs.
Effective and sustainable fortification will be possible only if the public sector (that has the mandate and responsibility to improve the health of population), the private sector (that has experience and expertise in food production and marketing), and the social sector (that has the grass-roots contact with the consumer) collaborate to develop, produce, and promote fortified foods. Specifically, a multisectoral partnership needs to be built between industry, national governments, international agencies, expert groups, and other players, to work closely on specific issues relating to technology development, food processing and marketing, free-market approaches with minimum price support mechanisms, standards, quality assurance, product certification, social communications and demand creation, monitoring, and evaluation. With food fortification as a multistakeholder proposition, the private sector, especially food processing industry, is one of the main stakeholders. Even though the addition of essential micronutrients to commonly consumed foods is a public health intervention, it is obvious that food is not processed, transported, distributed, or marketed by the public sector. While the public sector identifies an appropriate food vehicle based on daily consumption and determines levels of fortificants to be added and issues guidelines to be followed, the
Regulations and Standards In order for governments to undertake effective food fortification activities, it is necessary to first ensure that laws and
The success of producing and distributing a micronutrientfortified product depends on the placement of a quality assurance program that includes controls for raw material quality, good manufacturing practices (GMP) for production and packaging, and quality testing of the final product. Documentation and training are important components.
148
Food Fortification
actual act of fortification and sale of fortified foods to the consumers is carried out by the private food industry. As a consequence adequate public–private partnership is identified as an enabling factor for successful fortification programs to reach the poor and vulnerable. Within a country, the role of food industry depends on whether a fortification program is mandatory or voluntary. Mandatory fortification is the addition of specified nutrients to certain foods required by national legislation. Fortification at population scale, called mass fortification, is usually mandatory, though not always. Examples are flour fortification and salt iodization commonly practiced in most of the industrialized countries and many developing countries. Voluntary fortification is when the addition of micronutrients by the food processors is permitted for certain foods following specified standards set by the government. Examples are the fortification of breakfast cereals and the addition of calcium to orange juice in industrialized countries and oil fortification or soy/fish sauce in some developing countries. Food fortification is perceived by the public and private sectors from slightly different angles. In the public sector, justifications for addition of essential nutrients to foods are widely accepted because it is considered one of the cost-effective solutions to the challenge of nutritional deficiency among large segments of world’s population. On the other hand for the private sector, there has to be a business case for food fortification either because it is required by the law or because it can be positioned as value-added product. While the public sector is set up to work primarily for public good, the private sector is not established for purposes of benevolence. Though public– private partnerships are conceptually appealing many concerns exist, it is important to recognize and respect the realities of the fundamental difference between the two sectors.
Consumer Awareness and Communications Even when there is little or no cost differential between a fortified and an unfortified food, consumer awareness is an important issue for the acceptance of a newly fortified product. Consumers must be made aware of the benefits of fortified foods through a credible source. Effective communication to consumers is an often overlooked but an essential part of effective fortification interventions. By demanding nutrient fortified foods, consumers empower themselves to achieve their full social, physiological, and economic potential (Griffiths, 2003). It is also important that consumers are aware of recommendations based on evolving science. For example, currently micronutrient requirements for all groups of people living with HIV/AIDS are the same as for healthy non-HIV-infected individuals of the same age, sex, and physical activity level. Any future changes to these recommendations based on new evidence should be communicated appropriately.
Monitoring and Evaluation As food fortification programs expand around the world, there will be increasing need to monitor the quality of the fortified food (in terms of its micronutrient content) and evaluate its contribution to the alleviation of micronutrient deficiencies. Monitoring activities should ensure that a fortified product
contains sufficient amount of the micronutrient and that it reaches the target population. While monitoring at production level is essential through quality assurance, monitoring also needs to be carried out periodically at various levels in the distribution chain – from production or importation to wholesale, retail, and household levels. As a final indication of effectiveness, a biological impact evaluation, conducted after say 2 or 3 years, will determine whether the micronutrients are being well absorbed and are reducing the prevalence of the deficiencies in the population. During these evaluations, problems not identified in the initial stages may be identified. For example, it is well recognized that folic acid fortification has resulted in a profound improvement in the nutritional status of women of child-bearing age and has a substantial effect on the original target by reducing neural tube defects. However, Rosenberg (2005) cautioned that there is a need for protocols to evaluate large sections of the total population because the possibility remains that certain segments of the exposed population, for example, those at risk of B12 deficiency, may benefit less and may even experience some adverse effects from an increase in folic acid intakes. To avoid this potential problem, as well as to improve the effect of folic acid fortification for the reduction of neural tube defects, it is recommended that B12 is also added along with folic acid during population wide fortification.
Global Experience with Food Fortification Food fortification has played a major role in the health of the populations in several developed and developing countries over the last 70 years, and many nutritional deficiencies have been eliminated. Progress has accelerated in the past decade. Today there are salt iodization programs in approximately 140 countries worldwide, 83 countries have mandated at least one kind of cereal grain fortification, 20 countries edible oils, 9 countries sugar, and several others rice, milk, and condiments. Multiple studies have demonstrated the effectiveness of food fortification in eliminating micronutrient deficiencies. The current low levels of iron deficiency in the United States are attributable to fortified sources. Almost one-fourth of iron intakes in the US diet come from fortified sources, much of that from flour products. In Canada, flour fortification with B vitamins began in Newfoundland in 1944. Within 4 years, deficiencies that were earlier found in nearly 20% of the population had dropped to negligible levels. After 1998, following the introduction of mandatory folic acid fortification of cereal grain products in the United States, Canada, and Chile, there has been a 30–70% reduction of neural tube defects in newborns. In Europe, a comparative analysis of dietary surveys suggests that fortified foods, especially voluntarily fortified breakfast cereals in France, Ireland, the United Kingdom, and Spain have contributed to increasing vitamin and mineral intakes during childhood and adolescence. National fortification programs were also in place in Denmark until 1987 and in Sweden until 1994. In the developing world, there has been a rapid growth in fortifying a wide range of foods during the last two decades. The most successful global fortification experience is the fortification of salt with iodine. Adding iodine to salt is a simple
Food Fortification
manufacturing process costing no more than 4 cents per person annually. A significant proportion of the populations in more than 120 countries have access to iodized salt. As of 2015, nearly 76% of the salt consumed in the world is being iodized, protecting nearly 80 million newborns each year from the threat of mental impairment caused by iodine deficiency (UNICEF State of the World’s Children, 2015). Successful salt iodization has reduced the incidence of goiter and cretinism, prevented mental retardation and subclinical iodine deficiency disorders, and contributed to improved national productivity. Building on the success with iodization, double fortification of salt with iodine and iron is gaining ground and can be integrated with established iodization processes. Double fortified salt is currently being produced in India and has the potential to be distributed through commercial channels and public programs to reach economically weaker sections of the population in many countries (Figure 4). Fortification of staple foods such as flour, oils, sugar, condiments, dairy products, and a range of processed foods with micronutrients is also growing (Mannar, 2006). As compiled by the Flour Fortification Initiative, more than 63 countries are fortifying all or some of their flour with iron, folic acid, and other nutrients covering 28% of the global market. In the Americas alone, fortification of wheat flour and industrially milled corn flour is almost universal. There is growing interest and action on wheat flour fortification in South and South East Asia. In the Middle East and North Africa, several countries started fortification by adding at least iron and folic acid to cereal flour. A recent program review by the Micronutrient Initiative reported that while prior to 1998, only one country (Saudi Arabia) was fortifying flour, currently 13 countries in the region produce and consume fortified flour on a national or subnational
Figure 4
Grain fortification legislation.
149
scale – reaching more than 81 million consumers. In Asia, national flour fortification is under implementation in Pakistan and Nepal while several states in India are planning to introduce it. In Africa, fortification of wheat and maize flours has been made mandatory in South Africa and Nigeria. Fortification is also being extended to cereal flour derivatives and processed baked products, complementary foods, noodles, and pastas. Globally 78 countries have legislation to mandate fortification at least one major cereal grain. Of these, 77 countries fortify wheat flour, 12 countries fortify maize products, and 5 countries fortify rice. The countries with legislation are blue on the map below. Click on the links at right for separate global maps reflecting grain availability and legislation. Costa Rica is the only country that mandates fortification of all three grains, and Papua New Guinea is the only country that requires only rice fortification. Currently 77 countries require fortification of wheat flour produced in industrial mills. All the mandatory countries fortify wheat flour with at least iron and folic acid except Australia which does not include iron, and Venezuela, the United Kingdom, and the Philippines which do not include folic acid. Additionally, seven countries fortify at least half their industrially milled wheat flour through voluntary efforts. We estimate that 31% of the world’s industrially milled wheat flour is fortified with at least iron or folic acid through these mandatory and voluntary efforts. Brazil, Colombia, Indonesia, the Dominican Republic, and the United States have large-scale rice fortification programs though rice fortification is not mandatory throughout these countries. Condiments, such as fish/soy sauces, fortified with iron are emerging as a major vehicle in parts of Asia (China, Vietnam,
150
Food Fortification
and Thailand). National programs are underway in these countries and are already having demonstrable impact. Developed countries have long fortified milk and breakfast cereals with vitamin A (and other vitamins and minerals), but in developing countries, sugar has so far been the most successful vehicle. In Central America, Guatemala’s sugar fortification program has virtually eliminated vitamin A deficiency; big reductions have also been seen in El Salvador and Honduras, where fortification was combined with supplementation. Similar approaches in Zambia beginning in 1998 demonstrated success so far in urban areas. Since the poorer segments of population in Africa and Asia do not consume as much sugar as they do in Latin America, countries such as Nigeria, Morocco, Yemen, Bangladesh, and Pakistan are implementing national programs to fortify cooking oils with vitamin A. The World Food Program (WFP) which provides food to displaced populations and in emergency situations has a long history of distributing fortified foods procured from industrialized countries. More recently the WFP is moving toward on-site milling and fortification of locally produced grains and has established a capacity to produce fortified blended foods in 13 of the world’s poorest countries including Nepal, Madagascar, Ethiopia, and Malawi. A national program to provide fortified milk to infants up to 18 months of age has helped reduce anemia in Chilean infants from 21% to around 1%. Fortified complementary foods provided through public feeding programs and commercial channels in Mexico, Ecuador, Chile, and India had significant health and developmental impacts on children. Where fortified foods do not reach, multiple ways to deliver micronutrients to homes to enable mothers to either add them into the cooking pot or to mix them into what they feed their infants have been tried. Labeled as complementary food supplements, these are available as water-dispersible or crushable tablets, sprinkles, or spreads that can be added to complementary foods just before feeding infants and young children. They are designed to provide one to two EARs of vitamins and minerals in a small volume and are easily integrated into existing food practices. Fortified lozenges (containing a combination of vitamins and minerals) are being distributed in India to children between 2 and 5 years of age, adolescent girls, and pregnant and lactating mothers. They offer an approach that simplifies distribution and assures intake of measured quantities of micronutrients and high compliance. Key features of successful fortification programs include (Darton-Hill and Nalubola, 2002): l l l l l
strong political commitment and the ability to enforce regulations in a facilitative manner; early private sector involvement and willingness to comply with regulations; public-sector backing including endorsement by professional medical organizations; financial support by donors; and active consumer education to raise awareness and promote demand.
Ultimately, the long-term sustainability of fortification programs is ensured when consumers are willing and able to bear the additional cost of fortified foods.
In parallel with efforts to expand food fortification in many parts of the world, new efforts are underway to enhance the inherent micronutrient content of staple foods (such as rice, maize, sweet potato, cassava, common beans, and wheat) through plant breeding. By producing plants that are dense in minerals and vitamins, a process referred to as ‘biofortification,’ there is a unique opportunity to infuse staple crops with essential micronutrients, while also breeding the crop for yield and resistance. This can be a feasible means of reaching deficient populations in relatively remote areas, with limited access to health programs, micronutrient supplements, or commercially marketed fortified foods. An early example of this is the orange sweet potato. Rich with vitamin A to build immune systems, trials are underway to incorporate into agricultural production. Early indicators are yielding positive results with increased vitamin A intakes among children in targeted countries. Other crops such as beans, cassava, and pearl millet are promising candidates to carry other micronutrients such as iron and zinc.
Issues and Challenges for Food Fortification Notwithstanding the considerable progress in food fortification over the past decade, there are major challenges to ensure that undernourished people especially in developing countries receive meaningful amounts of micronutrients through improved access to fortified foods. For example, although significant success has been achieved with salt iodization, in many countries the groups without access to iodized salt are those most vulnerable and in greatest need for protection against iodine deficiency. While the relatively easier task of getting the large- and medium-scale units to comply has been achieved, compliance by small and some medium-scale salt producers continues to pose challenges. Thus the strategies used to achieve 70% coverage of iodized salt globally will not necessarily result in addressing the challenge for the remaining 30% of the population. The time needed for a fortification intervention to become effective in developing countries is likely to be much longer than in developed countries because in the former, such vehicles as salt and flour are often processed in a large number of widely dispersed cottage-scale industries that are not professionally managed. The challenge faced while attempting to increase iron intake through fortification is the low bioavailability of dietary iron coming mainly from plant sources in countries having an iron deficiency anemia problem. Interactions among various micronutrients (e.g., iron and zinc) and other nutritional and nonnutritional causes of anemia pose as challenges to be overcome for enhanced effectiveness of interventions. In addition to these programmatic challenges, there are differences in perceptions about fortification. While it is well established that food fortification has positive impact on population’s health and well-being and outweighs by far any potential risk, historically there has been public opposition (in some countries) to the addition of a foreign substance to food or water. Opponents of fortification argue
Food Fortification
151
that education about a well-balanced diet is a more logical approach than fortification. At the other end of the scale, the nutritional supplement and vitamin industry promotes the view that it is better for people to consume multivitamin supplements. Other objections include potential toxicity concerns. It is important to understand the different view points but equally important to move forward, in a responsible way, with what is most beneficial to large numbers of people whose lives would otherwise be compromised without the essential vitamins and minerals in their diet. What is needed is a balanced approach. Hand-in-hand with food fortification interventions, efforts should focus to eliminate other underlying causes of the deficiency. For example, improvements in sanitation which result in decreasing hookworm infection may lead to improvements in iron status (through reduced blood losses). Vaccinations against measles may protect against infection from reduced resistance caused by vitamin A deficiency. Birth control will ultimately improve the standard of living of a family and make food more available and help to prevent iron and iodine deficiencies in both women and children.
Governments should improve their inspection and enforcement systems to ensure high-quality fortification and a level playing field for the producers. Effective regulatory monitoring and enforcement will notably require more robust national budget allocations. There is a need to generate more evidence to guide fortification policy and program design, to continually improve programs, and to demonstrate impact. For example, there is a lack of detail of foods consumed by various target groups, limiting understanding of potential food vehicles, use of fortified foods and quantification of the dietary gaps that persist for some nutrients. Progress requires more transparent accountability and global reporting. Continuing advocacy with all stakeholders – public, private, and civic is a high priority.
The Way Forward
References
A well-planned food fortification program can provide meaningful quantities of essential micronutrients to large populations on a permanent and self-sustaining basis. In most situations the enormous benefits of a carefully planned and implemented fortification program far outweigh any potential risks. Food fortification can thus be one of the most costeffective means of overcoming micronutrient malnutrition. Food fortification efforts need to be integrated within the context of a country’s public health and nutrition situation and a clearly defined component of an overall micronutrient strategy that uses a combination of interventions to address key deficiencies. Within the last decade, many large-scale food fortification initiatives (iodized salt, sugar, flour, and oil fortification) have been implemented in a number of countries around the world, but many more people could still benefit from fortification programs. A global summit on food fortification identified the following critical areas for action to accelerate progress on food fortification (Arusha Statement on Food Fortification, 2015):
The Arusha statement on food fortification [Online], 2015. Global Alliance for Improved Nutrition, Geneva. Available at: http://www.gainhealth.org/wp-content/uploads/ 2015/05/Arusha-Statement.pdf (accessed 19.06.2016.). Black, R.E., Allen, L.H., Bhutta, Z.A., et al., 2008. Maternal and Child Undernutrition Study Group. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet 371, 243–260. Bhutta, Z.A., Das, J.K., Rivzi, A., et al., 2013. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? Lancet 382, 452–477. Darnton-Hill, I., Nalubola, R., 2002. Fortification strategies to meet micronutrient needs: successes and failures. Proc. Nutr. Soc. 61, 231–241. Dwyer, J.T., et al., 2015. Fortification and health: challenges and opportunities. Am. Soc. Nutr. Adv. Nutr. 6, 124–131. Griffiths, M., 2003. Communicating the benefits of micronutrient fortification. Food Nutr. Bull. 24 (4 Suppl.), S146–S150. Lutter, C.K., Dewey, K.G., 2003. Proposed nutrient composition for fortified complementary foods. J. Nutr. 133, 3011S–3020S. Mannar, M.G.V., 2006. Successful food-based programs, supplementation and fortification. J. Pediatr. Gastroenterol. Nutr. 43, S47–S53. Moench-Pfanner, R., Laillou, A., Berger, J., December 2012. Large-scale food fortification: optimizing program implementation – country experiences and technical considerations. Food Nutr. Bull. Special Suppl. Rosenberg, I.H., 2005. Science-based micronutrient fortification: which nutrients, how much and how to know? Am. J. Clin. Nutr. 82, 279–280. Schauer, C., Zlotkin, S.H., 2003. “Home-fortification” with micronutrient sprinkles – a new approach for the prevention and treatment of nutritional anemias. Paediatr. Child Health 8, 87–90. UNICEF, 2015. The State of the World’s Children. United Nations Children’s Fund, New York. WHO/FAO, 2006. In: Allen, L., de Benoist, B., Dary, O., Hurrell, R. (Eds.), Guidelines on Food Fortification with Micronutrients. WHO and FAO, Geneva.
Modest but new investment is essential. Fortification is costeffective and largely self-sustainable; costs are built into markets and typically do not require further or continuous public subsidy. Governments need to invest in technical support, oversight, and compliance. The new investments are needed to build, improve, and sustain fortification programs. They are small in relation to leveraged costs, cost per beneficiary and overall returns, and tiny as a proportion of health spending. There is need for a major effort to improve oversight and enforcement of food fortification standards and regulations. Poor compliance with laws and regulation limits potential for impact and undermines effectiveness. Available data show adequate compliance with standards as low as 50% in many contexts.
See also: Global Burden of Disease; Iodine Deficiency and Its Prevention; Iron Deficiency and Its Prevention; Nutrition and HIV; Vitamin A Deficiency and Its Prevention.
Further Reading Bauernfeind, J.C., Lachance, P.A. (Eds.), 1991. Nutrition Addition to Foods: Nutritional, Technological and Regulatory Aspects. Food and Nutrition Press, Trumbull, CT. Copenhagen Consensus, 2012. Available at: www.copenhagenconsensus.com/ copenhagen-consensus-iii (accessed 18.05.15.). Dary, O., Freire, W., Kim, S., 2002. Iron compounds for food fortification: guidelines for Latin America and the Caribbean 2002. Nutr. Rev. 60, S50–S61.
152
Food Fortification
Haddad, L., 2013. Ending Undernutrition: Our Legacy to the Post 2015 Generation. Institute of Development Studies in Partnership with the Children’s Investment Fund Foundation, Sussex, UK. Hurrell, R. (Ed.), 1999. The Mineral Fortification of Foods. Leatherhead International Ltd, England. Mannar, M.G.V., 2003. Food fortification. In: Cabellero, B., Trugo, L.C., Finglas, P.M. (Eds.), Encyclopedia of Food Sciences and Nutrition, second ed. Academic Press, Oxford, pp. 2613–2621. MI, 1998. Food fortification to end micronutrient malnutrition. In: Proceedings of the Satellite Conference of the XVI International Congress of Nutrition. The Micronutrient Initiative, Ottawa. Nathan, R., 2000. Regulation of Fortified Foods to Address Micronutrient Malnutrition: Legislation, Regulations and Enforcement. Micronutrient Initiative, Ottawa. Nestel, P., Nalubola, R., Mayfield, E. (Eds.), 2002. Quality Assurance as Applied to Micronutrient Fortification: Guidelines for Technicians, Supervisors, and Workers Concerned with Nutrition. ILSI Press, Washington DC. Ottaway, P.B. (Ed.), 1993. The Technology of Vitamins in Foods. Black Academic & Professional, Glasgow.
Richardson, D.P., 1997. The addition of nutrients to foods. Proc. Nutr. Soc. 56, 807–825. UNICEF/MI, 2004. Vitamin & Mineral Deficiency: A Global Progress Report. The Micronutrient Initiative, Ottawa. World Bank, 2006. Repositioning Nutrition as Central to Development: A Strategy for Large Scale Action. World Bank, Washington, DC.
Relevant Websites http://www.ffinetwork.org – Food Fortification Initiative (last accessed 10.06.16.). http://www.gainhealth.org – Global Alliance for Improved Nutrition (last accessed 10.06.16.). http://www.harvestplus.org/ – Harvest Plus (last accessed 10.06.16.).
Introduction
consume, as widely documented (UNICEF, 2015; WHO/FAO, 2006), mainly staple foods, and hence, those foods need to provide a critical amount of micronutrients to prevent large population segments from developing or worsening micronutrient deficiencies. The potential contribution of large-scale fortification of staple foods and condiments toward filling the micronutrient intake gap cannot be ignored. The Lancet (2008 and 2013) Maternal and Child Nutrition Series, the Copenhagen Consensus, and Scaling Up Nutrition (SUN) Movement all recognize and endorse staple food fortification as a sustainable, cost-effective intervention with a proven impact on public health and economic development. Reducing micronutrient deficiencies and undernutrition has the potential to reduce by more than half the global burden of disability for children under age 5, to prevent more than one-third of global child deaths per year, and, in Asia and Africa, to boost GDP by up to 11%.
Relative contribution of interventions to eliminate micronutrient deficiencies
The human body requires minute quantities of vitamins and minerals, known as micronutrients, for growth, brain development, and immunity against diseases. Since the body cannot synthesize these nutrients, they need to be supplied through the diet or other external sources. When the intake or absorption of essential vitamins and minerals from the diet is inadequate (commonly referred to as ‘hidden hunger’), individuals and communities suffer serious consequences, including learning disabilities, impaired work capacity, illness, and death. This is exacerbated by the fact that commonly consumed plant-based diets and beverages such as tea and coffee are high in inhibitors and low in enhancers of micronutrient absorption. Micronutrient deficiencies can be effectively prevented and even eliminated if populations consume adequate quantities of the bioavailable forms of required vitamins and minerals on a continuous and ongoing basis. There is no single solution to combat the ‘hidden hunger.’ However, years of program experience identified several solutions which are not mutually exclusive but complement one another. The solutions include ingestion of oral supplements (tablets, capsules, and syrups), public health measures, food fortification, and other foodbased approaches. Figure 1 illustrates how these approaches could relate over time: for example, supplementation with high doses of micronutrients is a short-term measure to address a severe deficiency, and its use is envisaged to come down as the longer-term measures are established. Food fortification is a medium- to long-term solution to alleviate specific nutrient deficiencies in a population. It involves addition of measured amounts of a nutrient-rich ‘premix’ containing the required vitamins and minerals to commonly eaten foods during processing. During moments of economic crisis, populations with lower purchasing power
Concept and Application According to Codex Alimentarius (a collection of internationally accepted food standards, codes of practice, and guidelines), 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. Food fortification involves the identification of commonly eaten foods that are centrally processed so that fortification could be dovetailed into the food production and distribution systems. This also means that fortification within the existing food patterns does not change the dietary practices of the population and so does not require special individual compliance. Staple foods and condiments are the obvious choice for
Supplementation Public health measures
Fortification
Dietary improvement
Time Figure 1
Complementary micronutrient interventions.
International Encyclopedia of Public Health, 2nd edition, Volume 3
http://dx.doi.org/10.1016/B978-0-12-803678-5.00160-0
143
144
Food Fortification
fortification given their consistent consumption by large sections of the population. In most developing countries the choice of vehicles is limited to a handful of staple foods and condiments: cereals, oils and fats, sugar, salt, and sauces. The vitamins and minerals used for fortification typically include vitamins A, D, folic acid and other B-complex vitamins, iodine, iron, and zinc. There is, however, no one single model appropriate for all population segments, making it imperative to design and implement complementary approaches to ensure the greatest penetration of fortified food products. There are also specific situations where large-scale food fortification can be enhanced by targeted fortification to reach vulnerable population subgroups, such as home fortification for vulnerable families, complementary foods for infants and young children (micronutrient powders, lipid-based nutrient supplements, fortified blended foods, etc.), and special foods for older children and pregnant and lactating women (biscuits, yogurt, beverages, etc.) (Moench-Pfanner et al., 2012). While the addition of nutrients to foods can help maintain and improve the overall nutritional quality of diets, indiscriminate fortification of foods could result in overfortification or underfortification in the food supply and nutrient imbalances in the diets of individuals. Any changes in food fortification policy for micronutrients must be considered within the context of the impact they will have on all segments of the population and of food technology and safety applications and their limitations (Dwyer et al., 2015). The start-up cost for food fortification is relatively inexpensive for the food industry, and recurrent costs are rapidly passed on to the consumer. The benefits of fortification can extend over the entire life cycle of humans. It can thus be one of the most cost-effective means of overcoming micronutrient malnutrition. The economics of food fortification has played an important role in its implementation in public policy. Food fortification is not a new concept. Addition of nutrients to staple foods was introduced nearly 70 years back as a means of dealing with micronutrient deficiencies prevalent in Europe and North America. In industrialized countries, several nutritional deficiencies have been eliminated partly because of a normally varied and rich diet and partly because most such nations have for decades been fortifying widely consumed foods such as flour, salt, juices, margarine, milk, and sugar.
Food Vehicles Common food vehicles that can be fortified include wheat and wheat products, corn, rice, milk and milk products, cooking oils, salt, sugar, breakfast cereals, and condiments. As processed foods gain popularity and market reach in the developing world, they offer new channels for micronutrient delivery. Potential food vehicles can be presented as a three-tiered pyramid (Figure 2). Staple foods at the base of the pyramid are cost-effective to fortify on a mass scale. Basic foods such as breads and biscuits, packaged cereals and flours, and dairy products are in the middle; and value-added foods such as condiments, snacks, candies, convenience and ready-to-eat foods are at the top. Fortifying less expensive staple foods at the base of the pyramid results in broader dissemination of micronutrients throughout the population, particularly to the poor. Also, fortifying foods at the base of the pyramid has a better chance of fortifying products through the other tiers of the pyramid because staple foods are generally used to produce basic and value-added foods. Table 1 provides examples of typical food vehicles and nutrients added. Each food vehicle offers specific opportunities and constraints: Cereals: Staples such as rice, corn, and wheat that are milled at centralized locations have the potential to reach large populations and are used in several countries as vehicles for multiple nutrients. When staple cereals are milled at the community level, it poses a challenge because of quality and safety constraints. For fortifying whole grain cereals such as rice, there is now a technology to produce simulated riceshaped premix. Fats and oils: Cooking fats and oils offer an option to deliver fat soluble vitamins such as vitamins A and D. While they have an advantage in that they are often centrally refined and packed, there is still the challenge of a large proportion being sold in loose unbranded form. Packaging in opaque containers is critical to protect the vitamins from degradation.
Value-added foods e.g., condiments, beverages, convenience foods, candies
Planning and Implementation When a country or region is ready to implement food fortification, the process begins by identifying the commonly eaten foods that can act as vehicles for one or more micronutrients. Food fortification aims to provide meaningful levels of the nutrient (usually 30–50% of the daily adult requirements) at normal consumption of the food vehicle. The levels also need to take into account variations in food consumption so that the safety of those at the higher end of the scale and impact for those at the lower end are ensured. They should also consider prorated intakes by young children to ensure efficacious and safe dosages. Cost, bioavailability, sensory acceptability, and storage stability are some of the criteria that determine the best match between the nutrient and food vehicle.
Basic foods e.g., breads, biscuits, packaged cereals, dairy products
Staple foods e.g., whole grain and milled cereals, oils and fats, sugar, salt
Figure 2
Food product pyramid.
Food Fortification
Table 1
Examples of foods for fortification
Food vehicle
Nutrients
Salt Wheat and maize flours Rice Cooking oils and fats Sugar Condiments (sauces) Milk Complementary foods
Iodine (and iron) Iron, folic acid, vitamin A, and B vitamins Iron, vitamin A, and B vitamins Vitamins A and D Vitamin A Iron Vitamins A and D; iron Multiple vitamins and minerals
Condiments: Salt, sugar, spices, and sauces are attractive carriers. Some are processed centrally and consumed in regular quantities and offer great potential. Recent studies show the promise for salt double fortified with iron and iodine. Dairy products: In areas where milk is processed in dairies, this may offer an option for fortification with both vitamins and minerals. Value-added products: Given the global demographic shifts from rural to urban areas, a larger proportion of the population can now be reached via commercially processed foods and value-added products. However, the most vulnerable populations consume these higher priced products (such as snack foods or beverage drinks) only sporadically. A multifaceted approach of fortifying more than one food vehicle is a good strategy, especially when a universally consumed vehicle is not available. When multiple foods are fortified, each with less than the Estimated Average Requirements (EAR) per single serving, the possibility of consuming toxic levels of a micronutrient through excess consumption of a single food becomes more remote.
145
Europe. They are available to children through a Special Supplemental Nutrition Program for Women, Infants and Children (WIC) in the United States. Programs that supply fortified complementary foods to infants and young children have also been introduced in several developing countries (Lutter and Dewey, 2003). Where there are few centrally processed complementary foods, alternative mechanisms include home fortification where micronutrient mixes in daily dose sachets have been successful (Schauer and Zlotkin, 2003). Market-driven fortification: When food manufacturers take a business-oriented approach to fortify some of the products as value-added products complying with the specifications for permissible nutrients and quantities. Mass and targeted fortification programs would focus on those micronutrients that are in the greatest need by the general population. Cost becomes a factor and it is important to have the collaboration of different stakeholders, particularly those in government and the milling industries. On the other hand, market-driven fortification might lean toward those micronutrients that have the greatest recognition and appeal to the intended market, usually the higher socioeconomic group that would purchase the premium products. Cost is generally not an issue in this situation. Mandatory versus voluntary fortification: Based on compliance requirements, food fortification can be mandatory or voluntary. In mandatory fortification it is stipulated by a country’s law that certain foods should be fortified with specified nutrients and levels. On the other hand, in voluntary fortification the food industry is permitted to add micronutrients as long as it is within a framework of specifications. Mass fortification is generally mandatory; targeted fortification can either be mandatory or voluntary whereas market-driven fortification is voluntary.
Reach of Fortified Foods Based on the population that would benefit from the fortified food and the type of industry compliance, several types of fortification are described in the Guidelines on Food Fortification with Micronutrients (WHO/FAO, 2006). Mass fortification: When foods widely consumed by the general population are fortified where the population has an unacceptable public health risk of being or becoming deficient in specific micronutrients. Flour fortification with iron and folic acid is a good example. Targeted fortification: When fortification is aimed at specific subgroups of the population, thereby increasing the intake of that particular group rather than that of the population as a whole. Examples include complementary foods for young children or food rations for displaced populations. Complementary foods and home fortification: Among the targeted fortification, complementary foods need special mention. Infants and children under the age of 24 months have a different dietary pattern than adults. Industrially produced fortified complementary foods are recommended by pediatricians as an essential part of an infant’s diet beyond the age of 6 months complementary to breast milk and homemade foods. Fortified infant formulas and cereals are commonly fed to young children in North America and
Technology The actual mechanics of adding the nutrients to the food is technically simple. Technology of food fortification also considers cost, bioavailability, sensory acceptability, and storage stability. Some technical considerations in planning a food fortification program include: l
l l
l l
The food used as a vehicle should be consumed in fairly constant amounts so that fortification levels can be accurately calculated. To do this, it is important to understand the consumption patterns of the food vehicle across the country. If it is for targeted fortification, the consumption pattern of the specific target group is needed. The chosen food should be processed centrally in large enough units to permit controlled fortification. The addition of the micronutrients should be compatible within existing food production and distribution systems. There should be minimum loss of the nutrient during processing, storage, and final preparation of the food. There should be no change in taste, appearance, or color of the final product. The food should be affordable so that the low-income groups, which are more vulnerable to malnutrition, consume it.
146
Food Fortification
Depending on the food processing methods, the addition of the micronutrients can be facilitated using different approaches to maximize the nutrient retention: l
l l l l
l l
l
l
Dry mixing – for cereal flours, powder milk, powder beverages. This is one of the common mechanisms used for the addition of the nutrient premix to the food. Dissolution in water – for liquid milk, drinks, fruit juices, and in the water used for making bread, pasta, and cookies. Dissolution in oil – for the lipid-soluble vitamins for enrichment of oily products such as margarine. Spraying – as in iodization of salt and in corn flakes where the nutrients do not withstand the cooking or extrusion step. Adhesion – as in sugar fortification where the vitamin A in powder form is adhered to the surface of the sugar crystal by vegetable oil. Coating – as in rice where the vitamins are sprayed over the grain as a coating. Extrusion and dry mixing – simulated rice-shaped premix of micronutrients is produced through an extrusion process and dry mixed with regular rice. Encapsulation – as in double fortification of salt where iron compound is encapsulated in order to prevent interaction with iodine and the food matrix. Micronization – as in salt fortification where the particle size of an iron compound is reduced in order to increase its bioavailability.
Figure 3 depicts a simplified framework of how fortification of cereal flour takes place.
Selection of Nutrient Form The chemical form of the nutrients being added (fortificants) influences the bioavailability, chemical stability, appearance, and homogeneity of the fortified food product. Vitamins and minerals
Blended to make a premix
Added to foods during milling
The choice depends, in part, on its solubility in the gastric juice and also on its impact on sensory characteristics of the food itself. Iron compounds used as fortificants provide the best examples to explain this concept. The iron compounds may be classified as (1) soluble in water, (2) slightly soluble in water and highly soluble in dilute acid as in gastric juice, (3) insoluble in water and poorly soluble in dilute acid, and (4) chelated iron compounds. Highly water-soluble compounds such as ferrous sulfate have excellent bioavailability and are suitable for a variety of applications but could create problems of unacceptable taste and color in the presence of high moisture and lipid contents. In such situations less soluble forms of iron are chosen to ensure consumer acceptance. Due to its high bioavailability, use of sodium iron EDTA (chelated iron) is recognized more recently as the fortificant of choice for soy sauce, fish sauce, and whole wheat/maize flours. Table 1 summarizes the selection of iron compounds to fortify commonly used foods. Though not as extensive as in iron, similar choices are available for other nutrients also. The Guidelines on Food Fortification with Micronutrients provides a comprehensive overview on the choice of the nutrients for fortification (WHO/FAO, 2006). Research and development efforts have enhanced effectiveness of fortification technology. In the case of Vitamin A, work is ongoing to reduce loss of nutrient potency on storage through addition of antioxidants and other stabilizers. Better refining procedures and packaging have significantly improved the stability of iodine compounds in salt and vitamin A in cooking oils. In the case of iron, stabilizers and absorption enhancers could be added along with the fortificant to retain it in an absorbable form or improve absorption. The structure of the iron compounds can also been modified to improve absorption (Table 2).
In accordance with government regulations and technical specifications
Staple grains grown by the farmer
Fortified flour
The fortified flour is eaten as baked or cooked products resulting in healthier individuals and families
Figure 3
Schematic diagram of cereal flour fortification.
Food Fortification
Table 2
147
WHO recommendations for average micronutrient fortification levels Fortification level (ppm) according to flour consumption (g day 1)
Micronutrient
Flour extraction rate
Compound
<75 g day
Iron
Low
Folic acid Vitamin B12 Vitamin A Zinc
High Low or high Low or high Low or high Low High
NaFeEDTA Ferrous sulfate Ferrous fumarate Electrolytic iron NaFeEDTA Folic acid Cyanocobalamin Vitamin A palmitate Zinc oxide Zinc oxide
40 60 60 NR 40 5.0 0.04 5.9 95 100
1
75–149 g day 40 60 60 NR 40 2.6 0.02 3 55 100
1
150–300 g day 20 30 30 60 20 1.3 0.01 1.5 40 80
1
>300 g day
1
15 20 20 40 15 1.0 0.008 1 30 70
Source: Adapted from Hurrell, R., Ranum, P., de Pee, S., Biebinger, R., Hulthen, L., Johnson, Q., Lynch, S., 2010. Revised recommendations for iron fortification of wheat flour and an evaluation of the expected impact of current national wheat flour fortification programs. Food Nutr. Bull. 31, S7–S21.
Implementation
regulations provide legal authority and an adequate regulatory framework. Effective regulatory controls through established fortification standards protect consumers against the risk of purchasing and consuming nutritionally inadequate, deceptively mislabeled or misbranded, impure or unsafe foods. Regulations also create a ‘level playing field’ for food manufacturers and sellers.
When a country or region is ready to implement food fortification, the process begins by identifying the commonly eaten foods that can act as vehicles for one or more micronutrients. Food fortification aims to provide meaningful levels of the nutrient (usually 30–50% of the daily adult requirements) at normal consumption of the food vehicle. The levels also need to take into account variations in food consumption so that the safety of those at the higher end of the scale and impact for those at the lower end are ensured. They should also consider prorated intakes by young children to ensure efficacious and safe dosages. Cost, bioavailability, sensory acceptability, and storage stability are some of the criteria that determine the best match between the nutrient and food vehicle.
Quality Assurance
Economics
Partnerships
The start-up cost for food fortification is relatively inexpensive for the food industry, and recurrent costs are rapidly passed on to the consumer. The benefits of fortification can extend over the entire life cycle of humans. It can thus be one of the most cost-effective means of overcoming micronutrient malnutrition. The economics of food fortification has played an important role in its implementation in public policy. Premix is the single greatest expense in fortification programs, accounting for up to 70–90% of recurring fortification costs (Griffiths, 2003). In higher-income industrialized countries, such costs are generally absorbed into the consumer price of the fortified food. However, this is not always the case for lower-income countries. Millers operate on thin profit margins in risky business environments, and poor consumers are highly price sensitive and cannot necessarily absorb the additional costs of premix. As a result, in many instances, premix costs can be a serious deterrent to private sector involvement and compliance in fortification programs.
Effective and sustainable fortification will be possible only if the public sector (that has the mandate and responsibility to improve the health of population), the private sector (that has experience and expertise in food production and marketing), and the social sector (that has the grass-roots contact with the consumer) collaborate to develop, produce, and promote fortified foods. Specifically, a multisectoral partnership needs to be built between industry, national governments, international agencies, expert groups, and other players, to work closely on specific issues relating to technology development, food processing and marketing, free-market approaches with minimum price support mechanisms, standards, quality assurance, product certification, social communications and demand creation, monitoring, and evaluation. With food fortification as a multistakeholder proposition, the private sector, especially food processing industry, is one of the main stakeholders. Even though the addition of essential micronutrients to commonly consumed foods is a public health intervention, it is obvious that food is not processed, transported, distributed, or marketed by the public sector. While the public sector identifies an appropriate food vehicle based on daily consumption and determines levels of fortificants to be added and issues guidelines to be followed, the
Regulations and Standards In order for governments to undertake effective food fortification activities, it is necessary to first ensure that laws and
The success of producing and distributing a micronutrientfortified product depends on the placement of a quality assurance program that includes controls for raw material quality, good manufacturing practices (GMP) for production and packaging, and quality testing of the final product. Documentation and training are important components.
148
Food Fortification
actual act of fortification and sale of fortified foods to the consumers is carried out by the private food industry. As a consequence adequate public–private partnership is identified as an enabling factor for successful fortification programs to reach the poor and vulnerable. Within a country, the role of food industry depends on whether a fortification program is mandatory or voluntary. Mandatory fortification is the addition of specified nutrients to certain foods required by national legislation. Fortification at population scale, called mass fortification, is usually mandatory, though not always. Examples are flour fortification and salt iodization commonly practiced in most of the industrialized countries and many developing countries. Voluntary fortification is when the addition of micronutrients by the food processors is permitted for certain foods following specified standards set by the government. Examples are the fortification of breakfast cereals and the addition of calcium to orange juice in industrialized countries and oil fortification or soy/fish sauce in some developing countries. Food fortification is perceived by the public and private sectors from slightly different angles. In the public sector, justifications for addition of essential nutrients to foods are widely accepted because it is considered one of the cost-effective solutions to the challenge of nutritional deficiency among large segments of world’s population. On the other hand for the private sector, there has to be a business case for food fortification either because it is required by the law or because it can be positioned as value-added product. While the public sector is set up to work primarily for public good, the private sector is not established for purposes of benevolence. Though public– private partnerships are conceptually appealing many concerns exist, it is important to recognize and respect the realities of the fundamental difference between the two sectors.
Consumer Awareness and Communications Even when there is little or no cost differential between a fortified and an unfortified food, consumer awareness is an important issue for the acceptance of a newly fortified product. Consumers must be made aware of the benefits of fortified foods through a credible source. Effective communication to consumers is an often overlooked but an essential part of effective fortification interventions. By demanding nutrient fortified foods, consumers empower themselves to achieve their full social, physiological, and economic potential (Griffiths, 2003). It is also important that consumers are aware of recommendations based on evolving science. For example, currently micronutrient requirements for all groups of people living with HIV/AIDS are the same as for healthy non-HIV-infected individuals of the same age, sex, and physical activity level. Any future changes to these recommendations based on new evidence should be communicated appropriately.
Monitoring and Evaluation As food fortification programs expand around the world, there will be increasing need to monitor the quality of the fortified food (in terms of its micronutrient content) and evaluate its contribution to the alleviation of micronutrient deficiencies. Monitoring activities should ensure that a fortified product
contains sufficient amount of the micronutrient and that it reaches the target population. While monitoring at production level is essential through quality assurance, monitoring also needs to be carried out periodically at various levels in the distribution chain – from production or importation to wholesale, retail, and household levels. As a final indication of effectiveness, a biological impact evaluation, conducted after say 2 or 3 years, will determine whether the micronutrients are being well absorbed and are reducing the prevalence of the deficiencies in the population. During these evaluations, problems not identified in the initial stages may be identified. For example, it is well recognized that folic acid fortification has resulted in a profound improvement in the nutritional status of women of child-bearing age and has a substantial effect on the original target by reducing neural tube defects. However, Rosenberg (2005) cautioned that there is a need for protocols to evaluate large sections of the total population because the possibility remains that certain segments of the exposed population, for example, those at risk of B12 deficiency, may benefit less and may even experience some adverse effects from an increase in folic acid intakes. To avoid this potential problem, as well as to improve the effect of folic acid fortification for the reduction of neural tube defects, it is recommended that B12 is also added along with folic acid during population wide fortification.
Global Experience with Food Fortification Food fortification has played a major role in the health of the populations in several developed and developing countries over the last 70 years, and many nutritional deficiencies have been eliminated. Progress has accelerated in the past decade. Today there are salt iodization programs in approximately 140 countries worldwide, 83 countries have mandated at least one kind of cereal grain fortification, 20 countries edible oils, 9 countries sugar, and several others rice, milk, and condiments. Multiple studies have demonstrated the effectiveness of food fortification in eliminating micronutrient deficiencies. The current low levels of iron deficiency in the United States are attributable to fortified sources. Almost one-fourth of iron intakes in the US diet come from fortified sources, much of that from flour products. In Canada, flour fortification with B vitamins began in Newfoundland in 1944. Within 4 years, deficiencies that were earlier found in nearly 20% of the population had dropped to negligible levels. After 1998, following the introduction of mandatory folic acid fortification of cereal grain products in the United States, Canada, and Chile, there has been a 30–70% reduction of neural tube defects in newborns. In Europe, a comparative analysis of dietary surveys suggests that fortified foods, especially voluntarily fortified breakfast cereals in France, Ireland, the United Kingdom, and Spain have contributed to increasing vitamin and mineral intakes during childhood and adolescence. National fortification programs were also in place in Denmark until 1987 and in Sweden until 1994. In the developing world, there has been a rapid growth in fortifying a wide range of foods during the last two decades. The most successful global fortification experience is the fortification of salt with iodine. Adding iodine to salt is a simple
Food Fortification
manufacturing process costing no more than 4 cents per person annually. A significant proportion of the populations in more than 120 countries have access to iodized salt. As of 2015, nearly 76% of the salt consumed in the world is being iodized, protecting nearly 80 million newborns each year from the threat of mental impairment caused by iodine deficiency (UNICEF State of the World’s Children, 2015). Successful salt iodization has reduced the incidence of goiter and cretinism, prevented mental retardation and subclinical iodine deficiency disorders, and contributed to improved national productivity. Building on the success with iodization, double fortification of salt with iodine and iron is gaining ground and can be integrated with established iodization processes. Double fortified salt is currently being produced in India and has the potential to be distributed through commercial channels and public programs to reach economically weaker sections of the population in many countries (Figure 4). Fortification of staple foods such as flour, oils, sugar, condiments, dairy products, and a range of processed foods with micronutrients is also growing (Mannar, 2006). As compiled by the Flour Fortification Initiative, more than 63 countries are fortifying all or some of their flour with iron, folic acid, and other nutrients covering 28% of the global market. In the Americas alone, fortification of wheat flour and industrially milled corn flour is almost universal. There is growing interest and action on wheat flour fortification in South and South East Asia. In the Middle East and North Africa, several countries started fortification by adding at least iron and folic acid to cereal flour. A recent program review by the Micronutrient Initiative reported that while prior to 1998, only one country (Saudi Arabia) was fortifying flour, currently 13 countries in the region produce and consume fortified flour on a national or subnational
Figure 4
Grain fortification legislation.
149
scale – reaching more than 81 million consumers. In Asia, national flour fortification is under implementation in Pakistan and Nepal while several states in India are planning to introduce it. In Africa, fortification of wheat and maize flours has been made mandatory in South Africa and Nigeria. Fortification is also being extended to cereal flour derivatives and processed baked products, complementary foods, noodles, and pastas. Globally 78 countries have legislation to mandate fortification at least one major cereal grain. Of these, 77 countries fortify wheat flour, 12 countries fortify maize products, and 5 countries fortify rice. The countries with legislation are blue on the map below. Click on the links at right for separate global maps reflecting grain availability and legislation. Costa Rica is the only country that mandates fortification of all three grains, and Papua New Guinea is the only country that requires only rice fortification. Currently 77 countries require fortification of wheat flour produced in industrial mills. All the mandatory countries fortify wheat flour with at least iron and folic acid except Australia which does not include iron, and Venezuela, the United Kingdom, and the Philippines which do not include folic acid. Additionally, seven countries fortify at least half their industrially milled wheat flour through voluntary efforts. We estimate that 31% of the world’s industrially milled wheat flour is fortified with at least iron or folic acid through these mandatory and voluntary efforts. Brazil, Colombia, Indonesia, the Dominican Republic, and the United States have large-scale rice fortification programs though rice fortification is not mandatory throughout these countries. Condiments, such as fish/soy sauces, fortified with iron are emerging as a major vehicle in parts of Asia (China, Vietnam,
150
Food Fortification
and Thailand). National programs are underway in these countries and are already having demonstrable impact. Developed countries have long fortified milk and breakfast cereals with vitamin A (and other vitamins and minerals), but in developing countries, sugar has so far been the most successful vehicle. In Central America, Guatemala’s sugar fortification program has virtually eliminated vitamin A deficiency; big reductions have also been seen in El Salvador and Honduras, where fortification was combined with supplementation. Similar approaches in Zambia beginning in 1998 demonstrated success so far in urban areas. Since the poorer segments of population in Africa and Asia do not consume as much sugar as they do in Latin America, countries such as Nigeria, Morocco, Yemen, Bangladesh, and Pakistan are implementing national programs to fortify cooking oils with vitamin A. The World Food Program (WFP) which provides food to displaced populations and in emergency situations has a long history of distributing fortified foods procured from industrialized countries. More recently the WFP is moving toward on-site milling and fortification of locally produced grains and has established a capacity to produce fortified blended foods in 13 of the world’s poorest countries including Nepal, Madagascar, Ethiopia, and Malawi. A national program to provide fortified milk to infants up to 18 months of age has helped reduce anemia in Chilean infants from 21% to around 1%. Fortified complementary foods provided through public feeding programs and commercial channels in Mexico, Ecuador, Chile, and India had significant health and developmental impacts on children. Where fortified foods do not reach, multiple ways to deliver micronutrients to homes to enable mothers to either add them into the cooking pot or to mix them into what they feed their infants have been tried. Labeled as complementary food supplements, these are available as water-dispersible or crushable tablets, sprinkles, or spreads that can be added to complementary foods just before feeding infants and young children. They are designed to provide one to two EARs of vitamins and minerals in a small volume and are easily integrated into existing food practices. Fortified lozenges (containing a combination of vitamins and minerals) are being distributed in India to children between 2 and 5 years of age, adolescent girls, and pregnant and lactating mothers. They offer an approach that simplifies distribution and assures intake of measured quantities of micronutrients and high compliance. Key features of successful fortification programs include (Darton-Hill and Nalubola, 2002): l l l l l
strong political commitment and the ability to enforce regulations in a facilitative manner; early private sector involvement and willingness to comply with regulations; public-sector backing including endorsement by professional medical organizations; financial support by donors; and active consumer education to raise awareness and promote demand.
Ultimately, the long-term sustainability of fortification programs is ensured when consumers are willing and able to bear the additional cost of fortified foods.
In parallel with efforts to expand food fortification in many parts of the world, new efforts are underway to enhance the inherent micronutrient content of staple foods (such as rice, maize, sweet potato, cassava, common beans, and wheat) through plant breeding. By producing plants that are dense in minerals and vitamins, a process referred to as ‘biofortification,’ there is a unique opportunity to infuse staple crops with essential micronutrients, while also breeding the crop for yield and resistance. This can be a feasible means of reaching deficient populations in relatively remote areas, with limited access to health programs, micronutrient supplements, or commercially marketed fortified foods. An early example of this is the orange sweet potato. Rich with vitamin A to build immune systems, trials are underway to incorporate into agricultural production. Early indicators are yielding positive results with increased vitamin A intakes among children in targeted countries. Other crops such as beans, cassava, and pearl millet are promising candidates to carry other micronutrients such as iron and zinc.
Issues and Challenges for Food Fortification Notwithstanding the considerable progress in food fortification over the past decade, there are major challenges to ensure that undernourished people especially in developing countries receive meaningful amounts of micronutrients through improved access to fortified foods. For example, although significant success has been achieved with salt iodization, in many countries the groups without access to iodized salt are those most vulnerable and in greatest need for protection against iodine deficiency. While the relatively easier task of getting the large- and medium-scale units to comply has been achieved, compliance by small and some medium-scale salt producers continues to pose challenges. Thus the strategies used to achieve 70% coverage of iodized salt globally will not necessarily result in addressing the challenge for the remaining 30% of the population. The time needed for a fortification intervention to become effective in developing countries is likely to be much longer than in developed countries because in the former, such vehicles as salt and flour are often processed in a large number of widely dispersed cottage-scale industries that are not professionally managed. The challenge faced while attempting to increase iron intake through fortification is the low bioavailability of dietary iron coming mainly from plant sources in countries having an iron deficiency anemia problem. Interactions among various micronutrients (e.g., iron and zinc) and other nutritional and nonnutritional causes of anemia pose as challenges to be overcome for enhanced effectiveness of interventions. In addition to these programmatic challenges, there are differences in perceptions about fortification. While it is well established that food fortification has positive impact on population’s health and well-being and outweighs by far any potential risk, historically there has been public opposition (in some countries) to the addition of a foreign substance to food or water. Opponents of fortification argue
Food Fortification
151
that education about a well-balanced diet is a more logical approach than fortification. At the other end of the scale, the nutritional supplement and vitamin industry promotes the view that it is better for people to consume multivitamin supplements. Other objections include potential toxicity concerns. It is important to understand the different view points but equally important to move forward, in a responsible way, with what is most beneficial to large numbers of people whose lives would otherwise be compromised without the essential vitamins and minerals in their diet. What is needed is a balanced approach. Hand-in-hand with food fortification interventions, efforts should focus to eliminate other underlying causes of the deficiency. For example, improvements in sanitation which result in decreasing hookworm infection may lead to improvements in iron status (through reduced blood losses). Vaccinations against measles may protect against infection from reduced resistance caused by vitamin A deficiency. Birth control will ultimately improve the standard of living of a family and make food more available and help to prevent iron and iodine deficiencies in both women and children.
Governments should improve their inspection and enforcement systems to ensure high-quality fortification and a level playing field for the producers. Effective regulatory monitoring and enforcement will notably require more robust national budget allocations. There is a need to generate more evidence to guide fortification policy and program design, to continually improve programs, and to demonstrate impact. For example, there is a lack of detail of foods consumed by various target groups, limiting understanding of potential food vehicles, use of fortified foods and quantification of the dietary gaps that persist for some nutrients. Progress requires more transparent accountability and global reporting. Continuing advocacy with all stakeholders – public, private, and civic is a high priority.
The Way Forward
References
A well-planned food fortification program can provide meaningful quantities of essential micronutrients to large populations on a permanent and self-sustaining basis. In most situations the enormous benefits of a carefully planned and implemented fortification program far outweigh any potential risks. Food fortification can thus be one of the most costeffective means of overcoming micronutrient malnutrition. Food fortification efforts need to be integrated within the context of a country’s public health and nutrition situation and a clearly defined component of an overall micronutrient strategy that uses a combination of interventions to address key deficiencies. Within the last decade, many large-scale food fortification initiatives (iodized salt, sugar, flour, and oil fortification) have been implemented in a number of countries around the world, but many more people could still benefit from fortification programs. A global summit on food fortification identified the following critical areas for action to accelerate progress on food fortification (Arusha Statement on Food Fortification, 2015):
The Arusha statement on food fortification [Online], 2015. Global Alliance for Improved Nutrition, Geneva. Available at: http://www.gainhealth.org/wp-content/uploads/ 2015/05/Arusha-Statement.pdf (accessed 19.06.2016.). Black, R.E., Allen, L.H., Bhutta, Z.A., et al., 2008. Maternal and Child Undernutrition Study Group. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet 371, 243–260. Bhutta, Z.A., Das, J.K., Rivzi, A., et al., 2013. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? Lancet 382, 452–477. Darnton-Hill, I., Nalubola, R., 2002. Fortification strategies to meet micronutrient needs: successes and failures. Proc. Nutr. Soc. 61, 231–241. Dwyer, J.T., et al., 2015. Fortification and health: challenges and opportunities. Am. Soc. Nutr. Adv. Nutr. 6, 124–131. Griffiths, M., 2003. Communicating the benefits of micronutrient fortification. Food Nutr. Bull. 24 (4 Suppl.), S146–S150. Lutter, C.K., Dewey, K.G., 2003. Proposed nutrient composition for fortified complementary foods. J. Nutr. 133, 3011S–3020S. Mannar, M.G.V., 2006. Successful food-based programs, supplementation and fortification. J. Pediatr. Gastroenterol. Nutr. 43, S47–S53. Moench-Pfanner, R., Laillou, A., Berger, J., December 2012. Large-scale food fortification: optimizing program implementation – country experiences and technical considerations. Food Nutr. Bull. Special Suppl. Rosenberg, I.H., 2005. Science-based micronutrient fortification: which nutrients, how much and how to know? Am. J. Clin. Nutr. 82, 279–280. Schauer, C., Zlotkin, S.H., 2003. “Home-fortification” with micronutrient sprinkles – a new approach for the prevention and treatment of nutritional anemias. Paediatr. Child Health 8, 87–90. UNICEF, 2015. The State of the World’s Children. United Nations Children’s Fund, New York. WHO/FAO, 2006. In: Allen, L., de Benoist, B., Dary, O., Hurrell, R. (Eds.), Guidelines on Food Fortification with Micronutrients. WHO and FAO, Geneva.
Modest but new investment is essential. Fortification is costeffective and largely self-sustainable; costs are built into markets and typically do not require further or continuous public subsidy. Governments need to invest in technical support, oversight, and compliance. The new investments are needed to build, improve, and sustain fortification programs. They are small in relation to leveraged costs, cost per beneficiary and overall returns, and tiny as a proportion of health spending. There is need for a major effort to improve oversight and enforcement of food fortification standards and regulations. Poor compliance with laws and regulation limits potential for impact and undermines effectiveness. Available data show adequate compliance with standards as low as 50% in many contexts.
See also: Global Burden of Disease; Iodine Deficiency and Its Prevention; Iron Deficiency and Its Prevention; Nutrition and HIV; Vitamin A Deficiency and Its Prevention.
Further Reading Bauernfeind, J.C., Lachance, P.A. (Eds.), 1991. Nutrition Addition to Foods: Nutritional, Technological and Regulatory Aspects. Food and Nutrition Press, Trumbull, CT. Copenhagen Consensus, 2012. Available at: www.copenhagenconsensus.com/ copenhagen-consensus-iii (accessed 18.05.15.). Dary, O., Freire, W., Kim, S., 2002. Iron compounds for food fortification: guidelines for Latin America and the Caribbean 2002. Nutr. Rev. 60, S50–S61.
152
Food Fortification
Haddad, L., 2013. Ending Undernutrition: Our Legacy to the Post 2015 Generation. Institute of Development Studies in Partnership with the Children’s Investment Fund Foundation, Sussex, UK. Hurrell, R. (Ed.), 1999. The Mineral Fortification of Foods. Leatherhead International Ltd, England. Mannar, M.G.V., 2003. Food fortification. In: Cabellero, B., Trugo, L.C., Finglas, P.M. (Eds.), Encyclopedia of Food Sciences and Nutrition, second ed. Academic Press, Oxford, pp. 2613–2621. MI, 1998. Food fortification to end micronutrient malnutrition. In: Proceedings of the Satellite Conference of the XVI International Congress of Nutrition. The Micronutrient Initiative, Ottawa. Nathan, R., 2000. Regulation of Fortified Foods to Address Micronutrient Malnutrition: Legislation, Regulations and Enforcement. Micronutrient Initiative, Ottawa. Nestel, P., Nalubola, R., Mayfield, E. (Eds.), 2002. Quality Assurance as Applied to Micronutrient Fortification: Guidelines for Technicians, Supervisors, and Workers Concerned with Nutrition. ILSI Press, Washington DC. Ottaway, P.B. (Ed.), 1993. The Technology of Vitamins in Foods. Black Academic & Professional, Glasgow.
Richardson, D.P., 1997. The addition of nutrients to foods. Proc. Nutr. Soc. 56, 807–825. UNICEF/MI, 2004. Vitamin & Mineral Deficiency: A Global Progress Report. The Micronutrient Initiative, Ottawa. World Bank, 2006. Repositioning Nutrition as Central to Development: A Strategy for Large Scale Action. World Bank, Washington, DC.
Relevant Websites http://www.ffinetwork.org – Food Fortification Initiative (last accessed 10.06.16.). http://www.gainhealth.org – Global Alliance for Improved Nutrition (last accessed 10.06.16.). http://www.harvestplus.org/ – Harvest Plus (last accessed 10.06.16.).