Micro-nutrient deficiencies affect not only the poor. Less obvious but nonetheless important are the effects of today’s lifestyles in the developed world on nutritional status. There are increased food choices, yes, but low micro-nutrient densities. The hectic pace of life can lead to inadequacies in the diet, so that even in well-endowed societies people are increasingly looking to fortified foods to make up the deficiencies. Food fortification has for one reason or the other emerged as a non- complicated way to improve the nutritional value of a diet. It has been applied for decades to improve the nutritional status of target populations in various countries by adding value to simple, affordable staple foods. Indeed, in many countries fortification of staples such as wheat flour is mandatory, to replace nutrients lost through food processing or to reduce the prevalence of identified deficiencies.
To keep up in today’s busy world, people are multitasking, and when it comes to keeping up with their daily nutritional needs, they expect their foods to multitask as well. According to the 2009 International Food Information Council (IFIC) Functional Foods/Foods for Health Consumer Trending Survey, the great majority of Americans believe that food provides benefits beyond basic nutrition and are interested in how certain foods or food components can improve or maintain their health.
Today, many people can identify a specific food and/or food component and its associated health benefit. Historically food fortification, such as iodized salt or vitamin D-fortified milk, has served as a public health measure to address population-wide nutrient deficiencies. Now, there are calcium- and vitamin D-fortified juices, breads fortified with omega-3 fatty acids, and vegetable-oil spreads with plant sterols available for health-conscious consumers searching for foods with additional health benefits. These types of foods contain added nutrients and ingredients that may promote or support overall health and wellness in a variety of ways across many different body systems including heart, bone, digestive, eye and brain; weight management; and increased energy and immune health, among others.
Ideally, foods not only must meet consumer needs and preferences but also address nutrition, regulatory, safety and technical constraints. The European Food Safety Authority (EFSA), World Health Organization (WHO) and several countries, including the United States, United Kingdom, Australia, New Zealand and Canada, follow similar guiding principles when it comes to their fortification policies.
What Is It?
Food fortification is primarily the addition of one or more essential nutrients (for example, iron, vitamin A, folic acid, iodine) 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. It is a safe, effective way to improve public health and has been used around the world since the 1920s. Commonly fortified foods include staple products such as salt, maize flour, wheat flour, sugar, vegetable oil and rice.
Is It Necessary?
Shortfalls in nutrient intakes could result from changing lifestyles. Even those in affluent communities may not achieve recommended micronutrient intakes without fortification of the food supply. Consumption of vegetables, fruits, whole grains, milk and milk products may be lower than recommended. This makes some micronutrients – potassium, dietary fibre, calcium, and vitamin D – low enough to be a public health issue. Other vitamins of concern include iron, folate and vitamin B12.
As per World Health Organization (WHO), about two billion people worldwide suffer from micronutrient deficiencies because they are not getting essential daily dietary requirements. Many diets, especially those of the poor, contain insufficient amounts of these essential vitamins and minerals due to lack of variation and/or consumption of predominantly processed foods. Since most populations in resource-poor settings do not have access to adequate quantities of fruits, vegetables and meats, where micronutrients are abundant, they are vulnerable to long-term health problems and raise societal and public healthcare costs and potentially depress the country’s productivity.
Considering that providing vitamin supplements or tablets poses logistical and economic constraints in such resource-poor settings, food fortification provides a practical and inexpensive alternative.Diseases such as goitre, rickets, beriberi and pellagra were once common health problems in the early 20th century. Today, these diseases are rarely seen due to a series of food-fortification programmes that have helped stave off a multitude of nutrient deficiencies. According to the World Health Organization and the Food and Agriculture Organization of the United Nations, food fortification is the practice of deliberately increasing content of an essential micronutrient in a food, so as to improve the nutritional quality of the food supply and provide a public health benefit with minimal risk to health.
What Are Micronutrients?
Micronutrients are vitamins and minerals required in small amounts that are essential to our health, development and growth. Proper intake of vitamins and minerals can mean the difference between a healthy, productive life, and a life fraught with illness. Micronutrient deficiencies are the leading cause of mental retardation, preventable blindness, and death during childbirth. A lack of these important vitamins and minerals also has a profound impact on the body’s immune system. Beyond the enormous health implications, micronutrient malnutrition has a significant economic impact.
Fortification Is Not Enrichment
‘Fortification’ and ‘enrichment’ are terms used to describe the addition of nutrients to foods, but are two separate concepts. Enrichment refers to the restoration of nutrients lost during the handling, processing, or storage of foods, and levels are generally based on Food and Drug Administration (FDA) standards of identity. Fortification refers to the voluntary addition of nutrients at levels beyond those naturally occurring in the food. Globally, the decision to fortify products is left to individual food manufacturers. Voluntary fortification is a common practice in many countries. Many countries including the United States, Canada and Australia require mandatory fortification of certain staple foods with specific nutrient(s) to improve public health, such as the fortification of enriched flour with folic acid to reduce the risk of neural tube birth defects, and also restrict the fortification of foods with certain nutrients such as vitamin D.
Iodine in Salt – the First Fortification
During the 1921 American Medical Association (AMA) convention, two Ohio doctors presented findings from their clinical trial demonstrating the effectiveness of sodium iodide treatments for the prevention of goitre. It was found that without iodine the body could not properly synthesize thyroid hormones, which often resulted in an unsightly neck goitre or in more serious cases, mental retardation. Iodine deficiency generally occurs in areas where the soil has been depleted of iodine because of flooding, heavy rainfall, or glaciation.
Shortly after the publication of the results, Michigan became the first state to institute a public campaign to provide dietary iodine via salt. An extensive educational campaign that involved schoolteachers, ndustry as well as medical and public health communities helped increase consumer awareness about, and demand for, iodized salt so that by 1924 iodized salt was commonplace, despite the fact that iodization was never mandatory. Epidemiological studies following the implementation recorded a significant decline in the incidence of goitre, confirming the success of the programme. Most table salt continues to be fortified with iodine today.
Fortification in India
In India, fortification of salt with iodine (generally called iodization of salt) and fortification of Vanaspati (hydrogenated fats) with vitamin A is mandatory. The National Anaemia Control Program (started in 1970) distributes iron tablets to children, pregnant and lactating women, and the National Vitamin A Prophylaxis Programme (started in 1971) provides two mega doses of vitamin A to children 9–60 months annually. As per NFHS-3, the coverage under these programmes is very low. Anaemia continues to threaten the life and wellbeing of a large number of the population, and vitamin A deficiency remains a public health problem. Hence, provisioning of small amounts of micronutrients through fortification of multiple foods that are consumed by various population groups and are either distributed through public funded programmes like public distribution system (PDS), Integrated Child Development Services (ICDS), and Midday Meal (MDM) scheme, and/or sold through the open market commercial channels offers an opportunity to provide micronutrients on a sustained basis.
Constitutional Provisions and Policy Support
Article 47 of the Constitution is government of India’s commitment to improve the health and nutrition status of its people. It states: “The State shall regard the raising of the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties.”The National Nutrition Policy (NNP) also recommends fortification of staple foods to address widespread micronutrient malnutrition amongst the general population. The three large-scale ongoing
Fortification activities in India are:
- Iodization of salt: Iodization of salt with potassium iodate started in 1962 in a few districts and has since covered most states and union territories.
- Fortification of vanaspati: Fortification of vanaspati with vitamins A and D started more than 50 years ago and has been obligatory in India since 1953.
- Fortification of milk: The department of food, ministry of food and civil supplies, government of India, pioneered and initiated fortification of milk with vitamin A in 1980, by providing technical as well as financial support. Presently, many milk dairy federations/cooperatives, including Mother Dairy, are fortifying milk with vitamin A. Both iodization of salt and fortification of vanaspati are mandated under the law and milk fortification is strongly recommended in the National Nutrition Policy.
Government of India’s Guidelines and Recommendations Supporting Fortification of Foods to Be Provided under ICDS and MDM
- Via letter no.1-2/2006-CD-1, department of women and child, on 31 January 2006, recommended provision of fortified ready-to-eat foods for children below three years of age to tackle micronutrient deficiencies
- Via letter no. 5-9/2005/ND/ Tech/Vol. II, ministry of women and child development, government of India, on 24 February 2009, recommended fortification of nutritional supplement with 50 per cent RDA in compliance with the IMS Act
- The policy recommendation for MDM programme also suggests that double-fortified salt (salt fortified with iodine and iron) be used for cooking as school children have a high burden of micronutrient malnutrition.
- FSSAI permits fortification of wheat flour and clear wheat flour (aata and maida).
- As per Justice Wadhwa Committee Report 2007, wheat flour can be sold in PDS instead of whole wheat grain and voluntary fortification permissible in PDS.
- On July 2008, in the third meeting of the executive of National Nutrition Mission, the need to focus on micronutrient fortification was highlighted.
- India’s 10th Five-Year Plan recommends staple foods, especially flour fortification, as an important part of the strategy to tackle micronutrient malnutrition.
- The ministry of food processing industry, GOI, provides financial assistance for food fortification and for capital equipment and its installation.
- The ministry of consumer affairs, food and public distribution, department of food and public distribution, clearly recommends provisioning of fortified wheat flour through PDS.
Fortified Foods under Public Funded Programmes
- Fortified foods like the corn-soya blend (CSB) and Indiamix have been provided as supplementary nutrition for over three decades in the World Food programme- (WFP) and CARE-supported ICDS projects.
- Fortified biscuits were being provided as a nutritious snack to children (6–11 years) in primary
- schools in the states of Madhya Pradesh, Uttarakhand, Orissa and Chhattisgarh, prior to the universalization of MDM.
- From the mid-1980s to the mid-1990s, state governments including those of Bihar, Uttar Pradesh, Madhya Pradesh, Rajasthan, Kerala, Delhi and Pondicherry were providing fortified bread as one of the food items for supplementary nutrition under the ICDS programme.
- Many state governments including those of Rajasthan, Gujarat, Madhya Pradesh, Punjab and Haryana are providing fortified foods under the ICDS programme, especially for children aged 6–36 months, as take-home ration (THR).
- The government of Gujarat is providing fortified wheat flour for preparation of cooked meals under ICDS and MDM.
- ICDS programmes in West Bengal, Gujarat, Andhra Pradesh and Bihar are providing candies fortified with vitamin A, iron, folic acid and vitamin C to children aged 2–6 years as well as pregnant and lactating women.
- The government of West Bengal has been distributing sachets of multiple micronutrient powder or sprinkles to the mothers of children below two years of age at ICDS centres. The supplements are administered with any kind of food given to the children.
Vitamin D in Milk
In the early 20th century, rickets (soft bones and skeletal malformation from incomplete bone growth) was common among underprivileged children living in industrialized cities. Inadequate diet, poor hygiene, and lack of exercise were among the factors believed to play a role in the formation of this disease. The relationship between diet and rickets was not clearly understood until an English physician conducted the first experimental study on rickets with dogs. His observations of specific ‘anti-rachitic’ factors found in cod liver oil, butter and whole milk eventually led to the identification, purification and synthesis of vitamin D. Subsequently, the Food and Drug Administration (FDA) established a standard of identity (SOI) for milk which included the optional addition of vitamins A and D. Today, the majority of our milk is fortified with vitamin D. However, additional food sources of vitamin D are limited, so obtaining vitamin D solely through dietary sources can be challenging and many people fall short of their daily requirements for vitamin D.
Naturally occurring sources are also limited mostly to oily fish and cod liver oil. Besides milk, select foods such as cereals and orange juice may be fortified with vitamin D. Supplements may also be necessary and are readily available. Because certain brands rather than all items within a food category may be fortified, it may be helpful to check the nutrition facts on food packets.
Can All Foods Be Fortified?
Indiscriminate addition of nutrients to foods and the fortification of fresh produce, meat, poultry, or fish products is not allowed by many countries; fortification of unprocessed foods is prohibited in European countries. This is meant to help consumers understand the nutritional value of foods from each food group. Also, fortification of some types of foods such as sugars and some snack foods (for example, candies and carbonated beverages) is discouraged, so that consumers are not encouraged to choose fortified foods that are inconsistent with achieving dietary guidelines.
• How safe is fortified food for consumers?
Experiences in countries that are already fortifying show that fortified foods are completely safe for consumers and that the benefits are enormous. The amount of vitamins and minerals added to a specific food is usually set at a proportion of the individual’s daily requirement and is usually less than one-third of the total recommended dietary allowance (RDA). Fortification is always strictly monitored and by implementing stringent quality-control measures, companies can ensure that there is no excessive intake of a specific vitamin or mineral.
• How does fortification affect the shelf life of a product?
Fortification has no impact on the shelf life of a product. The vitamins and minerals have a shelf life of their own although they do become less active over time.
• Does fortification change the appearance, taste, texture and flavour of the food?
No. When deciding on the appropriate premix for food fortification, only those vitamins and minerals are considered, which will not change the appearance, taste, texture and flavour of the food. In some cases encapsulated micronutrients may be used to prevent the interaction of micronutrients with either the atmosphere or with other micronutrients. The concept is based on the fact that the consumer’s buying behaviour should not be affected by the fortification process.
• What is the cost of food fortification?
Cost of food fortification is miniscule, ranging from Rs 30 to Rs 100 per metric ton, or just about 3 to 10 paisa per kg of food, depending on the type and number of micronutrients added and the staple food that is being fortified.
• What do companies stand to gain from adopting fortification?
Experience has shown that when a leader in the food industry takes the first step by fortifying food on a voluntary basis, it can result in many other food companies following suit. This voluntary fortification of foods by the industry also gives confidence to governments to consider making the process of certain food products mandatory. In many countries, including India, forward-thinking food companies have started fortification voluntarily and have a good record of success.
• What claims is a company allowed to make to market their fortified foods?
Companies can state that their product is fortified or enriched with vitamins and minerals and they can indicate the levels of added micronutrients. In India, Food Safety and Standards Authority of India (FSSAI) has laid down science-based standards for articles of food and issued regulations to regulate their manufacture, storage, distribution, sale and import, to ensure availability of safe and wholesome food for human consumption and for matters connected therewith or incidental thereto. These can be viewed at http://www.fssai.gov.in/AboutFSSAI/FSSAct.aspx
Voice Action – National Edible Oil Fortification
The Government of India is committed to addressing the problem of micronutrient deficiencies and has been running a Vitamin A supplementation programme for children under five years for more than a decade. However, only 25 per cent of children under five years old have received a dose of vitamin A in the six months preceding the nationally representative National Family Health Survey III (2005–06). Also, there is no programme to cover children above five years, pregnant women, women in post-partum phase, and adults.
To supplement these efforts, Confederation of Indian Industry (CII) collaborated with Global Alliance for Improving Nutrition (GAIN) and Voice and launched an initiative on National Edible Oil Fortification aimed at advocating for oil fortification. The project aims at building consensus around fortification as an industry-led initiative and to generate evidence on the merits of business-led expansion of a fortified edible oil portfolio. The project will entail engagement with various stakeholders (business leaders, technical experts, nutritionists and policymakers) to build consensus on taking forward the agenda of largescale fortification of edible oils. Under the initiative, Voice, CII and GAIN together are organizing Stakeholder Consultation on Oil Fortification workshops across all major cities of India. The workshops began on 18 June 2015 in Jaipur, Rajasthan, and until 22 August 2015, covered 23 cities in 23 states and union territories across India.
Oils and fats, like carbohydrates and proteins, are major components of the human diet. Depending on the source, oils provide not only energy but also the essential fatty acids required for human growth and development. The fat soluble vitamins – vitamins A, D and E –mix uniformly with oils, making them an excellent, cost-effective vehicle for fortification with these micronutrients. For example, studies have shown that fortification of cooking oil with vitamin A improves intake amongst vulnerable populations without any increase in cooking-oil consumption.