Fortification is the practice of deliberately increasing the content of an essential micronutrient, such as vitamins and minerals (including trace elements) in a food, to improve the nutritional quality of the food supply and provide a public health benefit with minimal risk to health. 

Fortification is the practice of deliberately increasing the content of an essential micronutrient

Yuri Bhaga, a registered dietitian practising in Johannesburg, recently presented an informative CPD-accredited webinar on the topic of fortification in food. To watch the replay and still earn a CPD point, access the replay here. To request a CPD certificate for watching the replay, email john.woodford@newmedia.co.za   

The following article is based on Bhaga’s presentation.  

Fortification is: 

  • The addition of micronutrients to food/food products 
  • Targeted at the larger population  
  • There to support nutritional status  
  • A medium- to long-term basis approach to improving nutritional status  
  • “The process whereby nutrients are added to foods to maintain or improve the quality of the diet of a group, community or population.” – World Health Organization. 

It is important to distinguish the differences between fortification, enrichment and supplementation.  

Fortification increases nutrient content of food – regardless of whether those nutrients were present in the food prior to processing, to prevent nutritional deficiencies.   

Enrichment is adding nutrients back into foods that were present in the food but lost during processing, to maintain and improve the nutritional content of food product.  

Supplementation is a stand-alone product taken in addition to normal dietary food sources. It is concentrated sources of nutrients and other substances with the intention to correct or prevent nutritional deficiencies.   

Advantages of fortification 

  • Behaviour change not required 
  • No change in food characteristics 
  • Cost-effective solution 
  • Contains natural/near natural levels of micronutrients 
  • Reduction in serious disease
  •  impact on health outcomes 
  • Long-term solution to malnutrition. 

Disadvantages of fortification  

  • Possibility of overconsumption by specific groups 
  • Not reaching the very marginalised 
  • May not benefit infants/children 
  • Not a substitute for good nutrition 
  • Requires effective government and private collaboration 
  • Needs efficient and accurate evaluation and monitoring processes 
  • Does not address acute malnutrition/deficiencies. 

Why fortify?  

Foods are fortified for the purposes of addressing malnutrition, micronutrient deficiencies, restoration of lost nutrients, substitution of nutrients for alternative products, and population-scale nutrition status.  

Nutrition surveillance  

Nutritional surveillance involves the routine collection and collation of data which inform us about the nature and causes of nutritionally related disease. Initially, these were diseases arising from nutritional deficiencies (eg. anaemia, rickets, and osteoporosis) but they now include a whole range of conditions (eg. obesity, hypertension, cancers, coronary heart disease, and dental caries).  

A system was established to continuously monitor the dietary intake and nutritional status of a population or selected population groups using a variety of data collection methods, whose ultimate goal is to lead to policy formulation and action planning.  

Fortification highlights the importance of nutrition surveillance. For example, we have seen the benefits of folic acid in neural tube defect incidence reduction (US and Canada). Long-term monitoring is needed to make sure there are no long-term issues.  

There are four types of food security indicators that can be included in surveillance systems: energy deprivation, monetary poverty, dietary diversity, and subjective, experiential indicators.  

What is the difference between monitoring and surveillance? Monitoring is a regular observation while surveillance is a more intensive form of data recording than monitoring. Surveillance refers to a specific extension of monitoring where obtained information is utilised and measures are taken if certain threshold values related to disease status have been passed.  

History of fortification  

Industrialised nations have used fortification since the early 20th Century, for example in the 

US, the following fortification was used in the food indicated: 

  • 1920s – salt (iodine) 
  • 1930s – milk (vitamin D) 
  • 1940s – flour and bread (various micronutrients) 
  • 1980s – variety of food stuffs (calcium) 

In South Africa, we have the following: 

  • 1954 – salt (iodine) 
  • 2003 – bread flour and maize meal (various micronutrients). 

South Africa introduced a compulsory fortification programme in 2003, where by law all white and brown bread flour and all maize meal had to be fortified with eight vitamins and minerals. Already, the rate of neural tube defects in newborns has dropped in recent years, suggesting that the addition of folic acid to staple foods is doing its work, but vitamin A and iron are not showing the desired result.  

Any targeted interventions have to be designed in such a way that it does not cause something like vitamin A toxicity, because we don’t know how much of those vitamins a person is getting elsewhere in their diet, through eating a diverse range of fresh foods, for instance, as well as through fortification.  

One of the South African Food-based Dietary Guidelines for healthy eating is to make starchy foods the basis of most meals. Bread, wheat flour and maize meal are fortified with vitamin A, riboflavin, niacin, pyridoxine, thiamine, folic acid, iron and zinc.  

Future considerations  

  • There should be a multidisciplinary approach through public and private, as well as  NGOs and development agencies . 
  • We should addressing the gaps in nutrition by advocating for mandatory fortification. 
  • There should be a focus on scaling and improving fortification standards, compliance and monitoring. 
  • We need to generate more evidence to guide future of fortification 
  • We need to maintain consumer demand 
  • We need to keep up with the changing global food and nutrition landscape. 

Optimising food fortification for impact moving forward will be facilitated by improved accuracy of micronutrient intake and status data at the national level, a continued extension of the scientific and technical base, and overcoming the current bottlenecks in low-to-middle-income countries that include targeted advocacy to build new programs, improved regulatory monitoring, additional resources, increased transparency and accountability, and more evidence of points of integration between fortification programs and biofortificationprograms, infection control, improved hygiene, and better sanitation, while carefully monitoring changes in micronutrient malnutrition caused by rapid urbanisation, changing lifestyles, globalisation, and climate change impact.  

Summary  

  • Micronutrient deficiencies and their consequences can have devastating health impacts. 
  • Food fortification is ranked one of the highest-return interventions in global development. 
  • Fortification is a proven, sustainable, cost-effective and high-impact solution to address micronutrient deficiencies. 
  • Better follow-up implementation, compliance and monitoring is needed. 
  • There is a need to advocate for commitment for stronger legislation/policy.