Does it work?

Fortification has proven to have dramatic and positive effects on both individuals and nations. The best-known example is the drive for Universal Salt Iodization, which succeeded in increasing access to iodized salt from 20% of households in 1990 to 70% today, dramatically reducing global goiter rates and cases of cretinism. Examples of successful programs using other foods include:

Guatemala and Sugar
After mandatory fortification of sugar with vitamin A was introduced in 1988, the prevalence of vitamin A deficiency decreased from 22% to 5% in one year. (Vitamin A Sugar Fortification in Central America Experience and Lessons Learned, 2009. MOST, USAID.)

Chile and Wheat Flour
Within one year of adding folic acid to wheat flour, blood folate levels in women of reproductive age increased 3-to-4-fold and the neural tube defects spina bifida and anencephaly decreased by 51% and 45% respectively (Gottlieb: Prevention of Neural-Tube Defects in Chile).

China and Soy Sauce
Sentinel surveys in 21 health clinics found that anemia dropped by approximately one-third following the fortification of soy sauce with iron in 2003 (China Soy Sauce Fortification Project, 2010. GAIN)

Canada and Grain Products
Four years after folic acid fortification became mandatory in 1998, the rate of neural tube defects fell by 46%. (Serdula, Peña-Rosas, Maberly, Parvanta, Arbuto, Perrine, and Mei: Flour Fortification with iron, folic acid, vitamin B12, vitamin A, and zinc: Proceedings of the Second Technical Workshop on Wheat Flour Fortification, 2010. The United Nations University.)

 

Is it a good investment?

In 2008, some of the world’s top economists, including five Nobel laureates, analyzed the costs and benefits of various public health interventions. Their conclusion: fortification is one of the most-cost effective options. Depending on the food and the specific vitamins and minerals added, fortification costs only $0.05 to $0.25 per person per year. Gains in productivity and savings to a nation’s healthcare system are many times this cost. In Tanzania, for example, the World Bank calculates that deficiencies in iron, vitamin A, and folic acid cost more than $518 million (2.65% of GDP). The food fortification program being launched there is expected to yield $8.22 in benefits for each dollar spent.

 

Is it safe?

Yes. Many countries have safely fortified foods for years. In order to ensure the correct amounts of vitamins and minerals are added to each selected food, data is collected on how much of the particular food people in the country are eating. Next, careful selection of the amount of micronutrients to be added ensures people with deficiencies will benefit without putting those who eat large amounts of the food at risk. Once fortification begins, the producers then test each batch of food to make sure it has been correctly fortified. Government bodies periodically make independent checks at the factory to validate the accuracy of the producer’s tests.

 

What is Necessary for Success

Fortification is unique in terms of its benefits to public health because it relies on a strong partnership between government and the food industry. To succeed, a program generally needs five components:

 

What is the History?

The United States and Switzerland have fortified foods since the 1920s, when iodine was first added to salt. The fortification of oil-based products dates back to the same era, when food producers began adding vitamin A to margarine to mirror the levels naturally occurring in butter, which it was beginning to replace.

In the 1930s and 1940s, the United States began adding thiamin, niacin, riboflavin, and iron to flour, and vitamin D to milk. Since the 1940s, wheat and other flours have been fortified in numerous countries, both to replace micronutrients lost in the processing and as a public health intervention.

The fortification of sugar with Vitamin A started in Central America in the 1970s and has spread to many countries, including Zambia and Nigeria.

Beginning in the 1980s, UNICEF led a campaign to achieve Universal Salt Iodization. Today 34 countries around the world have achieved the Universal Salt Iodization goal, with 38 others on track to eliminate iodine deficiency. More than 60 countries fortify other foods to improve public health.

 

What foods can be fortified?

In order to positively impact public health, food used in fortification efforts should meet certain criteria. It should be eaten by a large number of the population in relatively consistent amounts and be compatible with the micronutrients being added (meaning they won’t cause changes in color, taste, or shelf life.) Finally, the selected food should be relatively inexpensive so that low-income families can benefit from the fortification. Successful examples include salt, sugar, oil, margarine, milk, wheat flour, maize meal, rice, tortilla mix, soy sauce, and bouillon cubes.

 

How does it work?

The process varies slightly depending on the food being fortified, but the major steps are common. Based on the nutritional needs of a population, commercial companies produce a blend of vitamins and minerals, called a premix. The premix is checked for safety and shipped to the food processor where–after initial processing, but prior to final packaging–it is added and mixed into the food using a feeder or dosifier. The added premix is carefully measured to ensure a safe and appropriate amount of vitamins and minerals has been included.