The growth and development of the human being depend heavily on vitamins and micronutrients. Despite making up a relatively modest portion of our diet, their absence contributes to underdevelopment and a number of diseases. Foods that contain additional nutrients that aren’t naturally present in them are referred to as fortified. These foods are aimed to boost nutrition and provide additional health advantages. For instance, fruit juices may include calcium, and milk is frequently fortified with vitamin D. An enhanced food is one that has had nutrients that were removed during manufacturing and put back in.

Many enhanced grains are refined grains. For instance, following processing, folic acid and iron may be reintroduced back into wheat flour. This is done to replenish the vitamin levels to their natural state and process these fortified foods with iron.

Fortified foods serve an important function in helping to cover the gap in nutrient inadequacies, notably for children, pregnant or breastfeeding women, persons on calorie-restricted diets, and maybe even people following vegetarian or vegan diets if they are not carefully managed. Food “analogues” that have been fortified with essential vitamins and minerals, like plant-based milk or meat substitutes, more closely seem like the nutrient profile of their usual dietary counterparts. They also help to ensure people are not depriving themselves of vital nutrients because they prefer or need these foods. Fortified foods are also used to replenish vitamins and minerals that may have been lost during preparation, handling, or storage.

Foods that have been fortified are a great approach to increase the consumption of important vitamins and minerals among the general population since they are readily available, affordable, and consumed on a daily basis. The following nutrients are typically added to different types of fortified food by food manufacturers:

• Vitamin A
• Vitamin D
• Vitamin B6
• Dietary fibers
• Calcium
• Iodized salt
• Magnesium
• Folate

Maternal and child undernutrition causes 45% of all deaths in children under five in low- and middle-income countries (LMICs). A pervasive problem in LMICs is hidden hunger or a chronic lack of essential vitamins and minerals in the diet. Deficiencies in one or more micronutrients such as iron, zinc, and vitamin A compromise millions of people’s physical and cognitive capacity. Overall, it has been estimated that micronutrient deficiencies account for about 7.3% of the global burden of disease, and iron and vitamin A deficiency rank among the 15 leading causes of the worldwide disease burden, contributing to the deaths of over one million children annually. The World Health Organization (WHO) estimates that 42% of children less than 5 years of age and 40% of pregnant women worldwide are anemic; pregnant women with severe anemia are twice as likely to die during or shortly after pregnancy than non-anemic women, and for their children, micronutrient deficiencies in utero can lead to low birth weight and brain and spinal defects.

When did we start to fortify our food?

Food fortification is defined as the practice of adding vitamins and minerals to commonly consumed foods during processing to increase their nutritional value. It is a proven, safe, and cost-effective strategy for improving diets and for the prevention and control of micronutrient deficiencies. In 2008 and 2012, the Copenhagen Consensus ranked food fortification as one of the most cost-effective development priorities. While mandatory food fortification has been used as a strategy to prevent micronutrient deficiencies in high-income countries (HIC)—dating as far back as the 1920s in Europe and North America when the first salt was iodized—it is still less common in LMICs where food systems are not delivering nutritionally adequate diets due the production and consumption of just a few major starchy food crops (maize, rice, wheat) with low micronutrient content and/or bioavailability (phytate). In the past two decades, food fortification has become increasingly popular in LMICs for several reasons, including rapid urbanization and increasing household purchasing power, leading to a greater proportion of the population relying on processed foods.

Industrial or large-scale food fortification (LSFF) is the addition of micronutrients during processing to commonly consumed foods such as salt, flours, oil, sugar and condiments. LSFF programs can be categorized as either mandatory—meaning they are initiated and regulated by the government—or voluntary where food processors add nutrients to their foods on their own volition but is still governed by regulatory limits. Mandatory fortification programs are increasingly common, especially when it comes to fortified flour and iodized salt. Salt iodization is perhaps the most common form and between 1990 and 2008, the number of households globally consuming iodized salt rose from 20% to 70%. Currently, over 130 countries have mandated iodized salt.

Mandatory wheat flour fortification was first introduced in 1942 and currently 85 countries have since mandated its use. In North and South America, addition of folic acid to wheat flour is mandatory to lower the risk of birth defects. Edible oils are an increasingly common vehicle for fortification, and thus far 27 countries have mandated oil fortification with Vitamin A; and 14 countries have mandated milk fortification, 11 countries fortify milk with both Vitamin A and D, one country (Costa Rica) is additionally fortifying with iron and folic acid, and two countries (China and Canada) are adding calcium, in addition to Vitamin A and D.

Sugar fortification with vitamin A began in the 1970s in Latin America and was first implemented in Guatemala in 1975 becoming a model for other countries because it resulted in a near tripling of vitamin A intake and a decrease in vitamin A deficiency from 22% to 5% in only one year. In Africa, there are mandatory sugar fortification programs in Malawi, Mozambique, Nigeria, Rwanda, Zambia and Zimbabwe.

Currently, over 140 countries globally have guidance or regulations in place for fortification programs, the majority of which are mandatory, and almost 140 countries are implementing national salt iodization programs of which 102 are mandatory, 85 countries mandate at least one kind of cereal grain (maize, rice or wheat) be fortified with iron and folic acid, and over 40 countries mandate the fortification of edible oils, margarine and/or sugar with vitamin A and/or vitamin D

What are the health benefits of fortified foods?

More than two-thirds of Americans don’t eat fruits or vegetables at least twice a day, and most don’t meet the recommended dietary guidelines. Worldwide, more than 2 billion people have micronutrient deficiencies because they aren’t getting enough essential vitamins and minerals each day. Many Americans also aren’t meeting the requirement for vitamins and minerals, especially children.

Fortified and enriched foods were introduced in the 1930s and 1940s. They were intended to help boost vitamin and mineral intake with foods that adults and children were already eating, like grains and milk. Historically, fortifying foods has been widely successful in the United States. Common diseases that are caused by nutrient deficiencies, like rickets and pellagra, have been virtually eliminated.

Even though fortification has increased vitamin and mineral consumption in the United States, there haven’t been studies on nutrients other than folic acid that show that fortified foods are improving our health. There are also concerns that fortified and enriched foods may be causing people to get harmful amounts of certain vitamins and minerals. Fortified and enriched foods can be a part of a healthy, nutrient-rich diet. But whether or not they’re beneficial depends on age and a few other factors.

Preventing diseases by addressing inadequacies: In rare circumstances, nutritional deficiencies might result in poor health. For this reason, certain governments ensure that a specific food is fortified. 

1. Addressing Nutritional Needs: Foods that have been fortified can be especially beneficial for those on restrictive diets. This kind of diet may be an option or a strategy to treat a disease or allergy. Some vegetarian and vegan diets, for instance, lack essential vitamins, such as B12. In these situations, fortified plant-based milk, cereals, and spreads containing the vitamin might be a smart choice.
2. Children’s Growth and Development: Getting adequate nutrition is essential for children since their bodies are still developing. Iron, zinc, and vitamin D deficits are just a few of the nutrients that can prevent growth and result in lasting issues. Along with a balanced diet, fortified foods can help meet kids’ nutritional needs.
3. Protect Older Adults: Our body is less able to absorb vitamins and minerals as we become older. In order to maintain strong bones, support digestion, and ward against cardiac problems, fortified meals can help maintain optimum micronutrient levels.
4. Helpful in Pregnancy: Women who are pregnant require more food than usual since they are also nourishing a developing child. They cannot consume enough vitamins even when they eat more. The void can be filled if they include or eat fortified foods in their meals. Folic acid, for instance, is a component of many fortified goods. The risk of birth abnormalities is decreased when pregnant women consume adequate folic acid in their diet.

Are all fortified foods healthy?

Children are particularly vulnerable to nutrient deficiencies. Without added vitamins and minerals, many children and teens don’t meet daily nutrient requirements. Fortified and enriched foods are important sources of nutrients for kids, especially for iron, zinc, and B vitamins. Unfortunately, many fortified or enriched foods are heavily processed and packaged. They often come with high sodium, fat, and sugar content. Fortification doesn’t make them inherently healthy or good for you.

Many younger children are also at risk of overdosing on some added vitamins, according to a report from the Environmental Working Group (EWG). The report showed that many fortified foods currently available contain levels of vitamins that aren’t appropriate for children. Many children may also exceed daily recommended values by eating a variety of fortified foods throughout the day, or by eating more than one serving. Nearly half of children ages 2 to 8 get too much zinc, and 13% consume too much vitamin A. These overdoses are potentially dangerous.

Fortified and enriched foods, especially foods not formulated for children, may not be safe for all children. The EWG recommends that children eat products with no more than 20 to 25% of the adult recommended daily value for vitamin A, niacin, and zinc. You can find this value on the nutrition label. While it’s still important to keep an eye on these nutrients, tweens and teens may benefit from including fortified or enriched foods in a balanced diet.

• Companies often add vitamins at dangerous levels. This level may be up to 100% of the recommended daily allowance in a single serving, possibly causing you to exceed the limit. Most people do not exhibit deficiencies to such an extent to warrant this much. Hyper-fortified foods, in extreme cases, can result in toxicity overload and irreversible organ damage.

Examples of problems from overconsuming vitamins A, E, B9, B12, calcium and iron include:

• Too much-added vitamin A reduces bone density in older adults, increases the risks of birth defects and liver damage, and is associated with higher overall mortality risk.
• Too much-added vitamin E can increase the risk of stroke.
• Too much added folic acid (vitamin B9) can decrease immunity or mask a vitamin B12 deficiency (commonly seen in vegetarians).
• Too much-added calcium can cause kidney stones.
• Too much iron raises the risk of diabetes and heart problems in individuals with hemochromatosis, a genetic condition that causes the body to store excess iron in the liver, heart, and pancreas.

• Fortification and enrichment upsets nature’s packaging. Your body does not absorb individual nutrients added to processed foods as efficiently compared to nutrients naturally occurring in whole foods. In short, all nutrients in whole foods have a purpose, working in concert to enhance the uptake and bioavailability of each other. A simple example is skim milk fortified with vitamins A and D. Skim and low-fat milk have been processed to remove the fat, thereby losing the fat-soluble vitamins A, D, and K. Although vitamins A and D are added back, our bodies cannot absorb them without a fat vehicle, nor can they function optimally without the assistance of vitamin K.
• Vitamins added to food are less bioavailable. Nutrient bioavailability refers to the proportion of nutrients your body can absorb and use. Most food companies inject synthetic versions of vitamins and minerals, which your body may process differently (or not at all) compared to the natural, food-based versions.
• Synthetic vitamins lack immune-boosting substances. All-natural foods contain a trove of antioxidants and phytonutrients that scientists have yet to identify, let alone replicate. A group of physicians from university schools of public health around the country published a review in the Annals of Internal Medicine asserting that dietary supplements carry few potential benefits and, in some cases, are more harmful than helpful.
• Elevated levels of certain vitamins and minerals can interact with prescription medications. Fortified foods and supplements can pose specific risks for people who are taking prescription medications, including decreased absorption of other micronutrients, treatment failure, and increased mortality risk. For example, calcium supplements have been found to interact dangerously with some heart and thyroid drugs.
• Vitamins often only need to be added because they were originally taken out. While the foundation of most of what we eat is healthy, nutritious food, unfortunately, the nutrients within often end up being lost during the heavy processing that occurs to create the final product that ends up on the store shelves. If vitamins and minerals are being added back to foods, how bad must the processing have been to knock out all the healthful goodness that was already there?

The average consumer who regularly eats fortified foods faces a few big issues. Many experts argue that your body does not absorb individual nutrients added to foods in the same way that it absorbs naturally occurring nutrients in whole foods, consumed alongside other complementary nutrients. A simple example: Skim milk is often fortified with vitamin A and D, which are fat-soluble vitamins—but the milk was processed to remove the fat. When you consume those vitamins without a fat source, you may not get the same degree of nutritional benefits.

Companies often add vitamins into food at incredibly high levels—up to 100% of the recommended daily amount into one serving of food. Since most of us don’t have severe deficiencies, eating a lot of enriched foods might cause you to exceed the recommended daily intake by a long shot.

This can mess with your digestion, for starters. Some individuals have trouble breaking down folic acid (which is necessary for the important process of methylation), for example, so eating enriched bread, pasta and cereal regularly could lead to decreased immunity or mask a vitamin B12 deficiency. In severe but thankfully rare cases, overconsumption of micronutrients can lead to toxicity overload.