Food fortification

Argentina

In Argentina, wheat flour must by law (Ley 25.630 of 2002)^[11] be fortified with iron, thiamine (vitamin B₁), riboflavin (B₂), niacin (B₃), and folic acid (B₉).^[12]

Colombia

Wheat flour sold in Colombia must by law be fortified with vitamin B₁, vitamin B₂, niacin (B₃), folic acid (B₉) and iron (Decreto 1944 of 1996).^[13]

El Salvador, Guatemala, Honduras and Nicaragua

The four countries, also called the C-4, all legally require wheat flour to be fortified with vitamins B₁, B₂, B_3, B₉, and iron.^[14][15]

Philippines

The Philippine law on food fortification has two components: mandatory (covering select staples)^[16] and voluntary (under the Sangkap Pinoy program). The latter has been criticized for covering only low nutritional-value food, namely, junk food, to enable them to be sold in schools.^[17]

United Kingdom

UK law (The Bread and Flour Regulations 1998)^[18][19] requires that all flour (except wholemeal and some self-raising flours) be fortified with calcium. Wheat flour must also be fortified with iron, thiamine (vitamin B₁) and vitamin B₃.^[20]

United States

In the 1920s, food fortification emerged as a strategy in the United States to address and prevent the lack of micronutrients in the population's diet. Specifically, it was discovered in the 1930s and 1940s, that micronutrient deficiency is often linked to specific diseases and syndromes. Consequently, the Committee on Food and Nutrition suggested that micronutrients be added to flour.^[21] In 1980, The Food and Drug Administration put into action its Food Fortification Policy which included six fundamental rules. In addition to establishing safety guidelines of food fortification, this policy aimed to ensure that food fortification was solely for when the supplemental micronutrient had a national deficiency and that the food chosen to provide that nutrient was consumed by enough of the population to make a change. This policy also emphasized the importance of clinical data, a shift from earlier policies which relied on dietary data alone.^[4] The 2002 farm bill (P.L. 107–171, Sec. 3013) requires the Administrator of USAID, in consultation with the Secretary of Agriculture, to establish micronutrient fortification programs under P.L. 480 food aid. Section 3013 replaces a pilot program similarly named and authorized in the 1996 farm bill (P.L. 104–127, Sec. 415). Under the programs, grains and other commodities made available to countries selected for participation will be fortified with micronutrients (e.g., iron, vitamin A, iodine, and folic acid).

Limited absorption

One factor that limits the benefits of food fortification is that isolated nutrients added back into a processed food that has had many of its nutrients removed does not always result in the added nutrients being as bioavailable as they would be in the original, whole food. An example is skim milk that has had the fat removed, and then had vitamin A and vitamin D added back. Vitamins A and D are both fat-soluble and non-water-soluble, so a person consuming skim milk without fats may not be able to absorb as much of these vitamins as one would be able to absorb from drinking whole milk. On the other hand, the nutrient added as a fortificant may have a higher bioavailability than from foods, which is the case with folic acid used to increase folate intakes.^[23]

Phytochemicals such as phytic acid in cereal grains can also impact nutrient absorption, limiting the bioavailability of intrinsic and additional nutrients, and reducing the effectiveness of fortification programs.^{[citation needed]}

Different forms of micronutrients

There is a concern that micronutrients are legally defined in such a way that does not distinguish between different forms, and that fortified foods often have nutrients in a balance that would not occur naturally. For example, in the U.S., food is fortified with folic acid, which is one of the many naturally occurring forms of folate, and which only contributes a minor amount to the folates occurring in natural foods.^[24]

Certain forms of micronutrients can be actively toxic in a sufficiently high dose, even if other forms are safe at the same or much higher doses. There are examples of such toxicity in both synthetic and naturally occurring forms of vitamins. Retinol, the active form of Vitamin A, is toxic in a much lower dose than other forms, such as beta carotene. Menadione, a phased-out synthetic form of Vitamin K, is also known to be toxic.^{[medical citation needed]}

Iodized salt

"Iodine deficiency disorder (IDD) is the single greatest cause of preventable mental retardation. Severe deficiencies cause cretinism, stillbirth and miscarriage. But even mild deficiency can significantly affect the learning ability of populations. [...] Today over 1 billion people in the world suffer from iodine deficiency, and 38 million babies born every year are not protected from brain damage due to IDD."—Kul Gautam, Deputy Executive Director, UNICEF, October 2007^[28]

Iodised salt has been used in the United States since before World War II. It was discovered in 1821 that goiters could be treated by the use of iodized salts. However, it was not until 1916 that the use of iodized salts could be tested in a research trial as a preventative measure against goiters. By 1924, it became readily available in the US.^[29] Currently in Canada and the US, the RDA for iodine is as low as 90 μg/day for children (4–8 years) and as high as 290 μg/day for breast-feeding mothers.^{[medical citation needed]}

Diseases that are associated with an iodine deficiency include: intellectual disabilities, hypothyroidism, and goiter. There is also a risk of various other growth and developmental abnormalities.^[30]

Special-purpose food

Special food products intended to serve as a large (if not only) part of the diet are generally extensively fortified to meet the nutritional needs of their users. Examples include:

• Infant formula^[3]
• Field and emergency rations
  • Meal, Ready-to-Eat,^[31] Humanitarian Daily Ration,^[32]: 9 and similar ready-to-eat packages
  • Food ration bars and high energy biscuits for humanitarian use^[33][34]
  • Therapeutic food used by the Unicef for treatment of undernutrition in children^[35]: 84
  • Fortified blended foods such as the Super Cereal used by the Unicef and other organizations in disaster response^[35]: 136
• Various medical food items such as enteral diets designed for the feeding tube
• Meal replacements

Folate

Folate (as a fortification ingredient, folic acid) functions in reducing blood homocysteine levels, forming red blood cells, proper growth and division of cells and preventing neural tube defects (NTDs).^[36] In many industrialized countries, the addition of folic acid to flour has prevented a significant number of NTDs in infants. Two common types of NTDs, spina bifida and anencephaly, affect approximately 2500-3000 infants born in the US annually. Research trials have shown the ability to reduce the incidence of NTDs by supplementing pregnant mothers with folic acid by 72%.^[37]

Niacin

Niacin (a form of vitamin B₃) has been added to bread in the US since 1938 (when voluntary addition started), a program which substantially reduced the incidence of pellagra.^[38] Pellagra was seen amongst poor families who used corn as their main dietary staple. Although corn itself does contain niacin, it is not a bioavailable form unless it undergoes nixtamalization (treatment with alkali, traditional in Native American cultures) and therefore was not contributing to the overall intake of niacin.^{[medical citation needed]}

Diseases associated with niacin deficiency include pellagra which consisted of signs and symptoms called the three D's-"dermatitis, dementia, and diarrhea." Others may include vascular or gastrointestinal diseases.^[39] Common diseases which present a high frequency of niacin deficiency include alcoholism, anorexia nervosa, HIV infection, gastrectomy, malabsorptive disorders, certain cancers and their associated treatments.^[39]

Vitamin D

Since Vitamin D is a fat-soluble vitamin, it cannot be added to a wide variety of foods. Foods that it is commonly added to are margarine, vegetable oils and dairy products.^[40] During the late 1800s, after the discovery of curing conditions of scurvy and beriberi had occurred, researchers were aiming to see if the disease, later known as rickets, could also be cured by food. Their results showed that sunlight exposure and cod liver oil were the cure. It was not until the 1930s that vitamin D was actually linked to curing rickets.^[41] This discovery led to the fortification of common foods such as milk, margarine, and breakfast cereals in the USA and in some European countries (some of which later forbade the practice due to finding neonates suffering from vitamin D intoxication).^[42]

Diseases associated with a vitamin D deficiency include rickets, osteoporosis, and certain types of cancer (breast, prostate, colon and ovaries). It has also been associated with increased risks for fractures, heart disease, type 2 diabetes, autoimmune and infectious diseases, asthma and other wheezing disorders, myocardial infarction, hypertension, congestive heart failure, and peripheral vascular disease.^[42]

Fluoride

Although fluoride is not considered an essential mineral, it is useful in prevention of tooth decay and maintaining adequate dental health.^[43][44] In the mid-1900s it was discovered that towns with a high level of fluoride in their water supply was causing the residents' teeth to have both brown spotting and a strange resistance to dental caries. This led to the fortification of water supplies with fluoride in safe amounts (or reduction of naturally occurring levels) to retain the properties of resistance to dental caries but avoid the staining caused by fluorosis (a condition caused by excessive fluoride intake).^[45] The tolerable upper intake level (UL) set for fluoride ranges from 0.7 mg/day for infants aged 0–6 months and 10 mg/day for adults over the age of 19.^{[citation needed]}