Definition of Fortification
In simple terms, food fortification is defined as a process where nutrients are added to food and drinks. This usually takes two forms
- Nutrients are added which could have been removed during food processing
- Nutrients are added that may not be naturally occurring in the foods or a higher concentration of nutrients is added even if they are naturally occurring in smaller amounts.
Scientifically speaking fortification is a deliberate process that is used to increase the content of essential micronutrients – vitamins, minerals which include trace elements like iron, cobalt, chromium, copper, iodine, manganese, selenium, zinc and molybdenum. Fortification helps to improve the nutritional quality of the food which gets translated to health benefits and offers no health risk. Food fortification is of several kinds.
- Mass fortification means these foods are fortified for the consumption of the general public
- Targeted fortification means food is fortified for specific population subgroups like complementary foods for young children or rations for displaced people
- Market driven fortification means that food manufacturers are allowed to voluntarily fortify foods available in the market
Food fortification has been going on for centuries but in the modern age mass fortification was used for the first time when iodine was added to salt in the 1920s to prevent goiter in Switzerland and USA; but is now prevalent in almost all countries. Since the 1940s industrialized countries have been fortifying cereals with thiamine, riboflavin and niacin to prevent Vitamin A, D and some vitamin B deficiencies. Denmark fortified margarine with Vitamin D and the United States fortifies milk with Vitamin D. Some children’s foods are fortified with iron to prevent anaemia. Recently wheat has begun to be fortified with folic acid in the American continent.
Importance of Micronutrients
To lead a healthy and active life human beings need nutrients which are available in a balanced diet. Different physiological activities require different nutrients and so the amount of required nutrients depends a person’s age, body weight and physical status. Adults need nutrients for various body functions and to maintain constant weight. Infants and children on the other hand require two to three times the adult requirement of nutrients as they are growing rapidly. Micronutrient deficiencies can cause frequent illness in children which could lead to more serious illness. Malnourished children start school late and their performance levels are also lower. Pregnant and lactating women need additional nutrients because the growing foetus needs them for growth and later the mother needs them for milk secretion so the infant can grow and remain healthy.
The World Health Organization (WHO) considers that more than 2 billion people worldwide suffer from vitamin and mineral deficiencies, mainly iodine, iron, Vitamin A and zinc.
- Iodine deficiency leads to goiter, hypothyroidism, iodine deficiency disorders, increased risk of stillbirths, birth defects, infant mortality and cognitive impairment.
- Iron deficiency leads to anemia, reduced learning and work capacity, increased maternal and infant mortality, low birth weight. Zinc deficiency is higher in developing countries and is the cause of stunting and inability to resist infectious diseases.
- Vitamin A deficiency affects many preschool children and leads to night blindness and xerophthalmia. It also reduces the body’s ability to absorb calcium which can lead to rickets, a bone softening disease. Vitamin D deficiency was once very common in children in the industrialized countries but is now widespread and can also lead to osteoporosis and bone fractures. Elderly can become permanently handicapped and so reduces length and quality of life.
- Folic acid derived from Vitamin B6 and B12 can cause megaloblastic anemia, neural tube and other birth defects and also depression.
According to a WHO data, each year around 1.5% deaths are caused by iron deficiency and almost the same number because of Vitamin A deficiency. Besides, anaemia, caused by iron deficiency reduces the chances of a healthy life and iodine deficiency causes problems for about 0.2% of the total global population. Vitamin D deficiency, once very common in children in the industrialized countries, is now widespread and can lead to osteoporosis and bone fractures and can leave an elderly person permanently handicapped, thus reducing length and quality of life.
Current status of Indian and Global micronutrient deficiencies
Globally micronutrient deficiencies are quite high. In the developing countries more than 40% of women are anaemic, about 20% of the population suffers from iodine deficiency disorders (IDDs), and about 25% of children have vitamin A deficiency. However, clinically, Vitamin A deficiency is now falling as also iodine deficiencies in regions where the salt is iodized. Anaemia however, has not shown much improvement.
In India 50% women especially pregnant women and children suffer from anaemia. People are no longer going blind from Vitamin A deficiency but night blindness and Bitot from low levels of Vitamin A are still common. Vitamin B complex deficiencies like riboflavin, folic acid and perhaps Vitamin B12 are still common. Rickets may have become rare but recent studies in India show that there is Vitamin D deficiency as judged by serum levels of 25-hydroxy. Low Vitamin D levels along with low calcium levels could be responsible for the prevalence of osteoporosis in women in India. Iodine deficiency is mainly an environmental problem but it has been reduced because of ionization of salt for the general public. But because of lack of implementation some forms of iodine deficiency still exist. Also the presence of goitrogens in foods may also be contributing to iodine deficiency.
Global take on the fortification of foods
Milk has been fortified with Vitamin D since 1930s and has successfully reduced rickets. Milk seemed to be the best choice for fortification as it is easily available to children. Milk is also rich in calcium, phosphorus and other vitamins. Today we understand that bones are built with calcium, vitamin D, magnesium, potassium, phosphorus and high-quality protein. But rickets could be again resurging because of both vitamin D and calcium deficiency.
Globally it is now accepted that vitamin D receptors are present in various organs and tissues of the human body. If vitamin D is maintained in the blood at above 30 ng/ml it many ensure normal functioning of the body organs and protect those suffering from chronic ailments. Serum 25(OH) D levels less than 20 ng/ml cause health issues.
However, food fortification has now moved beyond enriching foods with vitamins and nutrients. Functional foods have now become an important aspect of fortification. These foods are seen to possess more health benefits than what is found in foods naturally. Consumers now have a choice of buying probiotic yoghurt, mayonnaise enriched with Omega-3 fatty acids and soft drinks and juices that have been fortified with vitamins and minerals. However, there are still several health concerns to be addressed before fortified foods are given the full green signal. Just suppose that foods have been fortified with vitamins and minerals but they could still contain high levels of sugars or sodium.
It is important that labels on fortified foods clearly display all nutritional and ingredient facts so that consumers can make the right choice depending on the disease they have or would like to prevent.
Common foods that are fortified all over the world
Food Vehicle | Fortifying agent |
---|---|
Salt | Iodine, iron |
Wheat and corn flours, bread. pasta, rice | Vitamin B complex, iron, folic acid, Vitamin B12 |
Milk, margarine, yoghurts, soft cheeses | Vitamins A and D |
Sugar, monosodium glutamate, tea | Vitamin A |
Infant formulas, cookies | Iron, vitamins B1, B2, niacin, vitamin K, folic acid, zinc |
Vegetable mixtures | Vitamins, minerals, amino acids, proteins |
Soy milk, orange juice | Calcium |
Juices and substitute drinks | Vitamin C |
Ready-to-eat breakfast cereals | Ready-to-eat breakfast cereals Vitamins and minerals |
Diet beverages | Vitamins and minerals |
Fortification of foods in India
In 2000, the Darjeeling district of West Bengal became the first place in India to fortify wheat flour. Every year almost 2.2 million tons or 12% of industrially milled wheat flour is fortified in Delhi, Rajasthan, Madhya Pradesh, Andhra Pradesh, Kerala, and West Bengal. The government supports flour fortification. Several state governments and their ministries and departments dealing with cereal grains and food distribution are involved in wheat fortification as well as international agencies, national health and nutrition research institutions.
In Odisha a pilot project by World Food Project (WFP) is underway where ordinary rice provided by the State is fortified with iron using state-of-the-art technology. The objective is to reduce anaemia and boost school children’s immune systems so they can fend off common diseases. This rice is being served in midday meals and children have begun to show better health. Besides this caregivers and relevant government officials are receiving training on child nutrition, cooking and feeding practices.
Rajasthan has a high rate of micronutrient malnutrition. Through the Integrated Food Fortification programme each month 15 million people receive fortified foods. More than 4,500 metric tonnes of wheat flour, 8,900 metric tonnes of oil and 41,000 metric tonnes of milk are being fortified per month. The project supports the government in training supervisors and cooks, of the school mid-day programme, on health, hygiene and nutrition. The programme also assesses government regulatory labs, to build the capacity for food-safety and also assesses medical officers in charge of regulatory monitoring.
The state of Madhya Pradesh (MP) also has very poor nutritional levels. Almost 88% of children between the ages 1 to 5 have subclinical vitamin A levels. Overall dietary intake is less than 50% of the recommended daily allowance (RDA); and 80% percent of the urban population has vitamin D deficiency. Soyabean oil has been identified as a fortifiable micronutrient vehicle, as MP is a soybean-oil producing state. Soyabean oil is one of the cheapest edible oils available in the market and almost all households use it. The fortification project involves collaboration with 13 MP based soyabean oil refineries where they will be provided Vitamin A and D premixes which are to be used to fortify oil.
Advantages and limitations of food fortification as a strategy to combat micronutrient malnutrition
Since it is food based, fortification has many advantages to prevent and control micronutrient malnutrition (MNM)
- If consumed regularly then the body will be able to store nutrients more efficiently and effectively. Fortified foods can help lower multiple deficiencies caused by poor diet. This is especially good for children who need them for growth and women of reproductive age to have healthy pregnancies and to supply sufficient nutrients to their babies during lactation.
- Fortified foods generally add only those levels of micronutrients that would be available from a well balanced diet and so fortifications are as close as possible to “natural” levels.
- Fortification is the best way to improve the nutritional level of a large number of people without changing their existing food habits. This is possible because even at the local level people in most countries are consuming foods that have been industry processed. This makes it possible to fortify foods with several micronutrients simultaneously. If the fortification is carried out at the point of manufacture then it becomes cost effective.
- If properly regulated fortification carries a minimal risk of chronic toxicity.
Fortification may be a good idea but it is still not a replacement for a good quality balanced diet. Some limitations that need to be addressed are as follows
- It is possible that a fortified food may not be consumed by all the people in the target group. Fortified foods will be consumed by the whole population whether they require the fortification or not.
- Since infants and young children eat in small portions it is possible that they might not receive the recommended daily dose of vitamins and nutrients.
- Also fortified foods may not reach the poorest people, who are the most in need of fortification, as they may not have access to industrialized food products. It is possible that the food distribution system does not reach them and they rely on local food like rice and maize.
The issue of fortification levels of nutrients is still unresolved as well as the stability of fortifications and nutrient interactions. Change in taste is another issue, as targeted populations may not easily adapt to the change in taste of staple foods. Iron fortifications change the colour and flavour of some foods and can also cause destruction of Vitamin A and iodine. This could limit the amount of fortification that can be added to preserve taste and colour.
It is possible to add a mixture of vitamins and minerals to dry foods like cereals but reactions could occur in some foods or could cause the deterioration to the quality to the nutrients. There is still a lack of knowledge about all nutrients. We do know that calcium can inhibit the absorption of iron from fortified foods while Vitamin C increases absorption of iron. It might not seem so but there are many associated costs of food fortification like
- start-up costs
- expense of conducting trials for micronutrient levels, physical qualities and taste
- realistic analysis of the purchasing power of the expected beneficiaries
- recurrent costs involved in creating and maintaining the demand for these products
- cost of an effective national surveillance system to ensure that fortification is both effective and safe
Fortification of foods may be a good strategy and has been effective but it cannot go forward without effective government policies and support for research and distribution.
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