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124 Ceylon Me dical Journal
CME article (Series 10) – Nutrit ion - 2
Introduction
Food fortification (FF) is defined as the addition of
one or more essential nutrients 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 [1]. Fortification therefore differs from enrichment,
which is the process of restoring the nutrients to a food
removed during refinement or production. Fortification
commonly uses staple foods as vehicles to deliver
micronutrients generally lacking or not contained in
sufficient concentration in the diet of a population and
has been practiced since the 1930s to target specific health
con di tions such as iodi ne deficiency through the
iodisation of salt, anaemia through the fortification of
cereals with iron and vitamins, and neural tube defects
through the fortification of wheat flour with folic acid.
Food fortification includes biofortification, microbial
biofortification and synthetic biology; commercial and
industrial fortification, and home fortification. The several
types of FF are distinct because different techniques and
procedures are used to fortify the target foods. Bioforti-
fication involves creating micronutrient-dense staple crops
using traditional breeding techniques and/or biotech-
nology. Using biotechnology (genetic engineering) to
biofortify staple crops is more modern and has gained
much attention in recent years. The most popular example
of this approach is the transgenic ‘Golden Rice’containing
twice the normal levels of iron and significant amounts of
beta-carotene [2]. Microbial biofortification involves using
probiotic bacteria (mostly lactic acid bacteria), which
ferment to produce -carotene either in the foods we eat
or directly in the human intestine [3]. Commercial and
industrial fortification involves fortifying commercially
available products such as flour, rice, cooking oils, sauces,
butter etc. with micronutrients and the process occurs
during manufacturing. Home fortification consists of
supplying deficient populations with micronutrients in
packages or tablets that can be added when cooking/
consuming meal s at home (basically a merg er of
supplements and fortification).
Fortification strategy to reduce micronutri-
ent deficiency
Food fortification has lowered the incidence of
micronutrient deficiencies (MNDs) that were previously
common, and has, improved the health status (and also
other key indicators, such as economic and educational
Food fortification
Ceylon Medical Journal 2011; 56: 124-127
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status) of a large proportion of the population(s) involved
[4]. In 2002 the World Health Report identified iodine,
iron, vitamin A and zinc deficiencies as being among the
world's most serious health risk factors [5]. The four key
str at egies identifi ed to address MNDs a re: dietary
improvement, supplementation, FF and global public
health and other disease control measures. FF is recognized
as one of the most cost effective methods. Short-term
strategies such as nutrient supplementation (giving a large
dose of the micronutrient as a medicinal supplement)
have been effective in providing immediate relief in several
countries, but this approach was not sustainable in the
long term [6]. The World Bank, WHO, UNICEF, Micro-
nutrient Initiative (MI) and Global Alliance for Improved
Nutrition (GAIN) also have identified fortification, as
among the most cost-effective of all health interventions
[4] and fortification of staple foods with micronutrients is
the strategy gain ing momen tum currently in many
developing countries [4].
Complementary feeding with fortified food
products
While fortified complementary foods are widely
used in industrialised countries, they are beyond the
reach of the poor in developing countries. The challenge
is to increase the density of complementary foods with
multiple fortifications of essential micronutrients at
affordable prices. Three types of fortified products
(precooked or instant) have been developed for infants
and young children: fortified blended foods (FBF),
com p l emen tary fo od su pplements (CFS), a n d
micronutrient powders (MNP). FBFs and CFSs have
been formulated to be prepared as semisolids or solids
(not liquids) that can replace traditional porridges so
that they are less likely to interfere with breastfeeding
and complying with local and international regulations,
including the International Code on Marketing of Breast-
Milk Substitutes and many relevant Codex Alimentarius
standards, including hygiene, additives, forms of added
micronutrients, and protein quality [7, 8]. The MNPs have
been developed to be used as “point-of-use fortificants”
or “home fortificants” [9]. Feasibility of iron sprinkles
as a point-of-use fortificant on homemade complementary
foods has shown to increase absorption of iron [10].
Some other types of fortified complementary foods, such
as cookies or biscuits and compr essed bars, also have
been used in emergency feeding programmes for young
children.
125
Vol. 56, No. 3, Septe mber 2011
CME article (Series 10) – Nutrit ion - 2
Food fortification in developed countries
The expanding range of fortified foods has been
justified by the fact that recommended dietary allowances
for many nutrients are commonly not met through the
normal diet. While FF continues to be widely used, the
regulation of fortification is currently receiving more
attention than the technologies involved because there
is a legitimate fear of over-fortification as manufacturers
seek to use fortification as a marketing tool. However,
the virtual elimination of micronutrient deficiencies in
developed countries has been attributed in large par t to
fortification [6]. Although it is well recognised that FF is
one of the preferred and cost-effective approaches in
combating micronutrient malnutrition, its effectiveness
in developing countries is yet to be demonstrated. One
of the limiting factors is the lack of simple and affordable
technology to fortify foods with stable and bioavailable
nutrients without compromising commonly accepted
taste and appearance [3].
Food fortification in less developed
countries
In south East Asia, progress has been made in
reducing iodine deficiency through salt iodisation. In
central American countries, fortification of sugar with
vitamin A demonstrated an improvement in vitamin A status
of the population. In the past two decades, flour
fortification with iron has been implemented in Chile and
Venezuela, resulting in an improvement in the iron status
of the population. Asian societies are predominantly rice
eating and the technologies to fortify rice are limited. With
rising consumption of wheat flour in Asia, many countries
such as India, Indonesia and the Philippines initiated
programmes for fortification of flour with iron, vitamin A,
folic acid and other B vitamins. In Sri Lanka, fortification
of wheat flour was experimented but a positive effect was
not found. In Thailand, other foods like noodles and fish
sau ce are fortified with micro-nutrien ts. Yet, vast
populations in the region still remain affected by MND.
However, as opposed to the developed ones different
considerations are involved in the establishment of FF
programmes such as, identification of the need for
nutritional intervention, determine required levels of
for tifi cation, selecti on of appropria te carrier and
fortificants, determination of technologies to use in the
fortification process and lastly the determination of some
mechanism to assess whether the nutritional objectives
of the programme are being met.
General principles of FF and quality control
A technical consultation on FF convened by the FAO
in 1995 focused on technology and quality control, and in
addition, the Codex Alimentarius Commission (1995) has
adopted the general principles for the addition of essential
nutrients to Foods [6]. Although these general principles
of FF are recognised internationally, incorporating them
into domestic law requires a clear understanding of the
nutrition problem involved [3, 5]. While its effectiveness
is not in doubt, FF needs to be controlled by appropriate
legislation. Adherence to legislation will ensure that the
objectives of a food-fortification programme are achieved
and that the levels of micronutrients are controlled within
safe and acceptable limits.
Problem identification
In order to successfully develop and implement a FF
programme, a country needs to have a clear understanding
of the nature of the nutrition problem (5) by collecting
information on extent and severity of the problem, whether
it affects different demographic groups, implications,
commitment of government and producers for addressing
the problem, major causes and resources available.
Bioavailability of fortificants
Absorption of added nutrients, particularly iron and
zinc, varies widely depending on the fortificant used. The
nature of the food vehicle, and/or the fortificant, may limit
the amount of fortificant that can be successfully added.
Selection of the form of micronutrient to be used as a
fort ifying agen t requires consideration of the bio-
availability, ch emical and physical properties of both
the fortifying agent and the food to be fortified [6].
Benefits and experience in rice fortification
on micronutrient status
Decades of research on rice enrichment and forti-
fication practices have provided a better understanding
of the technology needed; however, functionally suitable
and bioavailable iron fortificants have to be developed
and attention needs to be directed to improving stability
of added nutrients [11]. The appearance, textur e, taste,
and aroma of enriched rice must be evaluated to assess
consumer acceptability and coating mixtures containing
micronutrients have been developed for rice fortification
[12]. Fortifying flour is much simpler because the
nutrients that are available in powdered form can simply
be mixed into the flour. We have reported that fortification
of rice flour with iron, zinc and folate increased the
absorption of ir on and zinc in preschool children, in
addition to the improvements shown in their growth and
micronutrient status [13]. The sensory evaluation carried
out by us revealed that the acceptability of fortified rice
flour was high. As such, rice flour was recommended as
a suitable vehicle for fortification.
126 Ceylon Me dical Journal
CME article (Series 10) – Nutrit ion - 2
Table 1. Different types of food fortifications – pros and cons
Economic Environmental Ethical Legal Social Others
Industrial
fortification Pros Can be made available Does not interfere large populations do
at a low cost, restores with the natural have the ability to
the micronutrients lost state of plant or purchase commercial
in processing/cooking animal species foods
Cons Producers may increase May be viewed as Producers of the People who can't some people are too
the price unethical to place commercial goods afford commercial far from markets to
substances in must agree to foods won't benefit, purchase commercial
people's food the terms of may not reach all produ cts
without their fortification segments of the
consent population
Home fortification Pros Can be distributed as Not disturbing the The approach is not Encourages self-reliance
widely and cheaply natural state of plant forced on any person,
or animal species it is their choice to People’s behavior
utilize the additives patterns are not effected
Cons Not a sustained No changes made People may feel No guarantee the Requires education
approach as the supply in the normal food uncomfortable adding targeted population programme
of additives must be intake a substance to their will participate
replenished by a food without knowing
producer outside what it is
Bio fortification Pros Once introduced, Trace mineral can Large population Well suited approach
(Genetically highly sustainable help plants resist benefited since it utilizes the
Modified) and require minimal disease and fact that the daily
intervention environmental diet of low income
stressors micronutrient deficient
populations, is large
quantities of staple foods
Cons Lack of knowledge Many may believe Regulation and quality Farmers and consumers
on the impact on that nature shouldn't control strictly needed may not accept sensory
local eco systems be altered changes of biofortified
Mono cultures may crops
reduce biodiversity
127
Vol. 56, No. 3, Septe mber 2011
CME article (Series 10) – Nutrit ion - 2
Advantages and limitations of food fortifi-
cation
Being a food based approach FF has severa l
advantages over other interventions as it does not
necessitate a change in dietary patterns of the population,
can deliver a significant proportion of the recommended
dietary allowances for a number of micronutrients on a
continuous basis, and does not call for indi vidual
compliance. It could often be dovetailed into the existing
food production and distribution system, and therefore,
can be sustained over a long period of time.
If consumed on a regular and frequent basis, fortified
foods will maintain body stores of nutrients more efficiently
and more effectively than will intermittent supplements.
Fortified foods are also better at lowering the risk of the
multiple deficiencies, an important advantage to growing
children who need a sustained supply of micronutrients
for growth and development, and to women of fertile age
who need to enter periods of pregnancy and lactation
with adequate nutrient stores.
The limitations of FF are also well known: FF alone
cannot correct micronutrient deficiencies when large
numbers of the targeted population, either because of
poverty or locality, have little or no access to the fortified
food, when the level of micronutrient deficiency is too
severe, or when the concurrent presence of infections
increases the metabolic demand for micronutrients. In
addition, various safety, technological and cost consi-
derations can also place constraints on FF interventions.
Thus proper FF programme planning not only requires
assessment of its potential impact on the nutritional status
of the population but also of its feasibility in a given
context. Further, it needs to be controlled by appropriate
legislation [5]. Table 1 further illustrates the pr os and
cons of different types of FF programmes that can be
implemented.
References
1. Codex Alimentarius. (1991) General Principles for the Ad-
dition of Essential Nutrients to Foods – CAC/GL 09-1987
(amended 1989, 1991). Accessed online at http://www.codex-
alimentarius.net
2. Lonnerdal B. Genetically modified plants for improved trace
element nutrition. Journal of Nutrition 2003; 133: 1490-3S.
3. Sasson A. UNU-IAS Report. Food and nutrition biotech-
nology achievements, prospects, and perceptions. United
Nations University Institute of Advanced Studies (UNU-
IAS) Yokohama, Japan, 2005.
4. Darnton-Hill A, Nalubola F. Fortification strategies to meet
micronutrient needs: successes and failures. Proceedings of
the Nutrition Society 2002; 61: 231-341.
5. World Health Organization World Health Report. Geneva,
WHO, 2000.
6. International Life Sciences Institute Preventing micronutri-
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8. Codex Alimentarius. Guidelines for use of nutrition and health
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load/standards/351/CXG_023e.pdf
9. Stanley Zlotkin. Guidelines for the use of micronutrient
sprinkles for infants and young children in emergencies.
Sprinkles Global Health Initiative, Ottawa, Canada, 2008.
10. Liyanage C, Zlotkin S. Bioavailability of iron from micro-
encapsulated iron sprinkle supplement. Food and Nutrition
Bulletin 2002; 23; 133-7.
11. Lucca P, Hurrell R, Potrykus I. Fighting iron deficiency
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Nutrition 2002; 21: 1845-905.
12. Mannar V, Gallego EB . Iron fortification: Country level
experiences and lessons learned. Journal of Nutrition 2002;
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13. Hettiarachchi M, Hillmers DC, Liyanage C, Abrams SA.
Na2 EDTA enhances the absorption of iron and zinc from
fortified rice flour in Sri Lankan children. Journal of Nutri-
tion 2004; 134: 3031-6.
14. Hettiarachchi M, Liyanage C, Wickremasinghe R, Hillmers
DC, Abrams SA. Prevalence and severity of micronutrient
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C Liyanage1 and M Hettiarachchi2
1Department of Community Medicine, and 2Nuclear Medicine Unit, Faculty of Med icine, University of Ruhuna, Galle,
Sri Lanka.
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In order to determine the prevalence of micronutrient deficiencies (iron, zinc and folate) in Sri Lankan adolescent school children and the extent to which multiple micronutrient deficiencies exist in this population, a cross-sectional survey (2003) in the Galle district of the micronutrient and anthropometric status of 945 school children of ages 12-16 years was performed. The prevalence of anemia (Hb < 120.0 g/L) was 49.5% in males and 58.1% in females (overall 54.8%, gender difference, P = 0.004). In anemic children 30.2% of males and 47.8% of females were iron deficient (serum ferritin < 30.0 microg/L). Folate deficiency (<6.80 nmol/L) was found in 54.6% and 52.5% of boys and girls respectively whereas zinc deficiency (<9.95 micromol/L) occurred in 51.5% and 58.3%. Anemic boys had a 1.5 (95% confidence interval (CI) 0.9-2.6) and 1.6-fold (CI; 1.1-2.6) greater risk of being stunted and underweight, whereas the risk among anemic girls was 1.7 (CI; 1.1-2.7) and 1.0 (CI; 0.7-1.5) for being stunted and underweight. The relative risks of having at least two deficiencies in iron, zinc and folate among anemic children were 1.6 (CI; 0.6-4.2) among boys and 0.8 (CI; 0.5-1.5) among girls. Iron deficient subjects had a significantly increased risk of 1.8 (CI, 1.1-3.0) of being deficient in folate and 1.7 (CI, 1.2-2.6) of being deficient in zinc. Zinc deficient subjects had a risk of 1.3 (CI, 1.0-1.8) being iron deficient and 1.2 (CI, 0.9-1.7) of being folate deficient. Multiple micronutrient deficiencies are prevalent in Sri Lankan adolescents.
Conference Paper
Deficiencies of iron and zinc are common worldwide. Various strategies have been used to combat these deficiencies including supplementation, food fortification and modification of food preparation and processing methods. A new possible strategy is to use biotechnology to improve trace element nutrition. Genetic engineering can be used in several ways; the most obvious is to increase the trace element content of staple foods such as cereals and legumes. This may be achieved by introduction of genes that code for trace element-binding proteins, overexpression of storage proteins already present and/or increased expression of proteins that are responsible for trace element uptake into plants. However, even very high levels of expression may not substantially increase the iron and zinc contents unless many atoms of trace elements are bound per protein molecule. Another possibility is to introduce a protein that specifically enhances trace element absorption even in the presence of naturally occurring inhibitors, thus improving bioavailability. Genetically modifying plants so that their contents of inhibitors of trace element absorption such as phytate are substantially reduced is another approach. Increasing the expression of compounds that enhance trace element absorption such as ascorbic acid is also a possibility, although this has received limited attention so far. Iron absorption may be increased by higher ascorbic or citric acid content but require overexpression of enzymes that are involved in the synthetic pathways. Finally, a combination of all of these approaches perhaps complemented with conventional breeding techniques may prove successful.
Article
Iron fortification has been used to enhance iron intake in many developed countries for more than 50 years, but only in the last decade has this strategy been applied on a large scale to other parts of the world. Iron fortification of rice is being instituted in the Philippines. Initially, the rice will be produced in government-controlled rice mills and sold at low cost mainly to low income families. Efforts to improve the technology (using coating or extrusion techniques) are currently underway to reduce cost and minimize losses during storage and washing. Effectiveness and feasibility studies are required to test the new technologies and processing/distribution systems. In Venezuela in 1993, the government instituted a mandatory program of iron fortification to enrich precooked corn flour followed by the voluntary fortification of wheat flour. Surveys in school children subsequently showed a sharp drop in iron deficiency. Fortification of fish sauce in Vietnam has shown promising initial results in reducing anemia among anemic, nonpregnant female factory workers. Iron-fortified soy sauce has been shown to reduce anemia in initial studies in children in China, and a large-scale efficacy trial is now underway. These examples indicate that iron fortification of staple foods and condiments holds great promise for the prevention of iron deficiency.
Article
Iron deficiency is estimated to affect about 30% of the world population. Iron supplementation in the form of tablets and food fortification has not been successful in developing countries, and iron deficiency is still the most important deficiency related to malnutrition. Here we present experiments that aim to increase the iron content in rice endosperm and to improve its absorption in the human intestine by means of genetic engineering. We first introduced a ferritin gene from Phaseolus vulgaris into rice grains, increasing their iron content up to twofold. To increase iron bioavailability, we introduced a thermo-tolerant phytase from Aspergillus fumigatus into the rice endosperm. In addition, as cysteine peptides are considered major enhancers of iron absorption, we over-expressed the endogenous cysteine-rich metallothionein-like protein. The content of cysteine residues increased about sevenfold and the phytase level in the grains about one hundred and thirtyfold, giving a phytase activity sufficient to completely degrade phytic acid in a simulated digestion experiment. This rice, with higher iron content, rich in phytase and cysteine-peptide has a great potential to substantially improve iron nutrition in those populations where iron deficiency is so widely spread.
Article
To improve the iron status of infants an effort was made to increase the iron content of complementary foods by adding 12.5 mg of elemental iron to the meal in the form of micro-encapsulated ferrous fumarate coated with a lipid. The contents of the packet were sprinkled directly on to infant foods. Relative absorption of iron from this supplement was determined in a prospective randomized study with 39 infants (mean age 33.6 +/- 5.2 weeks) with initial hemoglobin values greater than 100 g/L. They were fed two complementary foods (rice-based and wheat-based) in which the supplement labeled with stable isotopes of iron 57Fe and 58Fe was incorporated. The erythrocyte iron incorporation was measured in the blood by inductively coupled plasma mass spectrophotometry. The incorporation of iron was significantly higher 11.9% p < .001 and 13.3% p < .001 and no difference was observed with the type of cereal in complementary foods. The use of ferrous fumarate sprinkles has proved to be efficacious in increasing the available iron intake of the infants.
Article
Deficiencies of iron and zinc are common worldwide. Various strategies have been used to combat these deficiencies including supplementation, food fortification and modification of food preparation and processing methods. A new possible strategy is to use biotechnology to improve trace element nutrition. Genetic engineering can be used in several ways; the most obvious is to increase the trace element content of staple foods such as cereals and legumes. This may be achieved by introduction of genes that code for trace element-binding proteins, overexpression of storage proteins already present and/or increased expression of proteins that are responsible for trace element uptake into plants. However, even very high levels of expression may not substantially increase the iron and zinc contents unless many atoms of trace elements are bound per protein molecule. Another possibility is to introduce a protein that specifically enhances trace element absorption even in the presence of naturally occurring inhibitors, thus improving bioavailability. Genetically modifying plants so that their contents of inhibitors of trace element absorption such as phytate are substantially reduced is another approach. Increasing the expression of compounds that enhance trace element absorption such as ascorbic acid is also a possibility, although this has received limited attention so far. Iron absorption may be increased by higher ascorbic or citric acid content but require overexpression of enzymes that are involved in the synthetic pathways. Finally, a combination of all of these approaches perhaps complemented with conventional breeding techniques may prove successful.
General Principles for the Addition of Essential Nutrients to
  • Codex Alimentarius
Codex Alimentarius. (1991) General Principles for the Addition of Essential Nutrients to Foods -CAC/GL 09-1987 (amended 1989, 1991). Accessed online at http://www.codexalimentarius.net
Food and nutrition biotechnology achievements, prospects, and perceptions
  • A Sasson
  • Unu-Ias Report
Sasson A. UNU-IAS Report. Food and nutrition biotechnology achievements, prospects, and perceptions. United Nations University Institute of Advanced Studies (UNU-IAS) Yokohama, Japan, 2005.