Food fortification is the addition of one or more essential nutrients to a foodstuff—food, food product, ingredient, or condiment—to prevent micronutrient deficiencies of one or more nutrients at the population level (Allen et al. 2006). Industrial food fortification refers to adding micronutrients and minerals to industrially processed and widely consumed edible products (Allen et al. 2006). Common fortified foods, for example, include salt; wheat and maize flours; edible oils; and sugar, but can also include bouillon cubes or soy sauce. Foods fortified with iron will likely have the highest impact on anemia, although foods fortified with other nutrients, such as vitamin A and folic acid, may also be important. One advantage of industrial food fortification is that it requires limited changes in consumer behavior compared to other micronutrient interventions.
You should consider the quality and coverage of industrial food fortification in the population, and whether it is reaching those who need it the most. Young children may not consume sufficient quantities of industrially fortified foods to meet their micronutrient needs and, thus, additional micronutrient interventions may be needed for this population. In addition, industrial food fortification may not reach populations who do not have access to markets; therefore, you should consider the reach of products to communities in rural or hard-to-reach areas. Small-scale fortification—for example, hammer mills to grind small batches of maize in East Africa—may, theoretically, fall under fortification legislation, but feasibility, compliance, and enforcement may be very limited.
Measurement and data sources
Key indicators for food fortification programs include having fortification policies at the national level, levels and type of fortificants available in fortified foods, availability of fortified foods, and consumption of fortified foods. Depending on the fortification interventions in your country, these indicators may or may not be relevant for all food vehicles.
To understand the policy environment for industrially fortified foods, review the legislation governing the fortification of food in the country to determine if it is mandatory, voluntary, or neither. If a law mandates fortification, or if fortification is voluntary, then the industries fortifying foods must ensure that their food meets the fortification standards. Fortification standards establish the levels (or ranges) of micronutrients expected to be found in the final packaged foods.
Do not assume that all industries comply with the standards—even if mandatory. Look for additional data from a governmental regulatory agency on external quality control results to establish, for example, the number of metric tons of adequately fortified wheat flour in the last year. The website or annual reports of the ministry governing the program may post summary data on how adequate the fortification of foods is at the production and retail levels.
Standardized methods can be used to verify the level of micronutrients in fortified foods—qualitative, semi-quantitative, and quantitative methods for determining the amount of iron, vitamin A, and other micronutrients in fortifiable foods. Qualitative methods add reagents that indicate the presence of micronutrients by forming a colored compound (e.g., blue color with trifluoroacetic acid when vitamin A is present in oil or sugar). Quantitative methods use procedures like spectrophotometry for iron in wheat flour; high-performance liquid chromatography for vitamin A in flour, sugar, and oil, and water soluble vitamins (thiamin, riboflavin, niacin and folic acid) in foods; and, microbiological assays for folic acid and vitamin B12 in fortified foods. This information may be available from industry, governments’ monitoring data, or population-based surveys.
A fortification rapid assessment tool is often conducted before a fortification program is implemented; it can be used with complementary monitoring data to understand reach and potential dietary impact of implementation. Once a fortification program is underway, you need to quantify the contributions of micronutrients from the different fortified foods to the diets of the population. The Global Alliance for Improved Nutrition (GAIN) developed the Fortification Assessment Coverage Tool to evaluate the potential dietary intake from fortified foods because of large-scale food fortification programs (GAIN 2016). The tool is used in population-based surveys to assess the coverage of fortifiable and fortified foods purchased or consumed at the household and individual level, and to test household food samples for their nutrient content.
Household-level consumption of a particular fortified food may also be found through consumer expenditure surveys, or other nationally or regionally representative datasets. These datasets vary from country to country, but it is often possible to add fortification-relevant questions to existing surveys or survey collection systems to understand the functioning of a food fortification program. Household surveys like Demographic and Health Surveys, Multiple Indicator Cluster Surveys, and household consumption and expenditure surveys may also collect information on the purchase or consumption of fortified and fortifiable foods.
The Food Fortification Initiative is a comprehensive source of data on fortification policies, fortification practices, industry information, and nutrient deficiencies across most countries, with a focus on maize flour, wheat flour, and rice. In addition, GAIN maintains information on food fortification programs on its website. The Iodine Global Network highlights some instances of fortification of salt with other nutrients.
- In countries where fortification is not mandated by law and the food industry does it voluntarily, it may be difficult to access data on monitoring at the production level. These data may only be available directly from the industries fortifying the foods, if at all. Because of market competition, most industries do not share their production data.
- In most countries where industrial food fortification is being implemented, a regulatory mechanism ensures that the foods being fortified meet the standards set within the country. The quality of the data from these regulatory agencies can vary, based on the resources they have to carry out production-level monitoring.
- Most countries with fortification programs do not have nationally representative data on the consumption of fortified foods. The coverage of these programs for the population at high risk of micronutrient deficiencies—children under 2, adolescent girls, and pregnant women—is often unknown. We rely on food consumption data, both fortified and non-fortified, as a proxy for their dietary micronutrient intake.
Allen, Lindsay, Bruno de Benoist, Omar Dary, and Richard Hurrell, eds. 2006. Guidelines on Food Fortification with Micronutrients. Geneva, Switzerland: World Health Organization and Food and Agriculture Organization.
Das, Jai K., Rehana A. Salam, Rohail Kumar, and Zulfiqar A. Bhutta. 2013. “Micronutrient Fortification of Food and Its Impact on Woman and Child Health: A Systematic Review.” Systematic Reviews 2: 67. doi:10.1186/2046-4053-2-67.
GAIN. 2016. “GAIN’s Fortification Assessment Coverage Tool (FACT).” Global Alliance for Improved Nutrition. Accessed June 15, 2016. http://www.gainhealth.org/knowledge-centre/gains-fortification-assessment-coverage-tool-fact/.