FOOD FORTIFICATION 2613
FOOD FORTIFICATION
M G Venkatesh Mannar, The Micronutrient Initiative,
Ottawa, Canada
Copyright 2003, Elsevier Science Ltd. All Rights Reserved.
Synopsis
0001 Vitamins and minerals (commonly termed ‘micro-
nutrients’) are essential for efficient energy metabol-
ism and other functions of the human body. Food
fortification is increasingly recognized as an effective
means of delivering micronutrients through com-
monly consumed foods. Fortification of foods can
provide meaningful amounts of the nutrient at
normal consumption of the food vehicle. The level
of fortification should take into account variations in
food consumption to ensure safety for those at the
higher end of the scale and impact for those at
the lower end. Fortification needs to be supported
by adequate food regulations and labeling, quality
assurance, and monitoring to ensure compliance and
desired impact.
Prevalence and Impact of Micronutrient
Deficiencies
0002 Many vitamins and minerals cannot be synthesized
by the human body. They must be provided by the
diet. They are necessary for the regulatory systems in
the body for efficient energy metabolism and for
other functions such as cognition, immune system,
and reproduction. The amounts needed are small –
micrograms or milligrams a day – so they are called
‘micro’ nutrients (Table 1). When intake of these
nutrients is inadequate, individuals and communities
suffer serious consequences, including learning dis-
abilities, impaired work capacity, illness, and death.
During rapid growth, micronutrient intake must
increase or else growth failure or deficiency diseases
develop. It is during these periods that deficiency
symptoms are most prevalent. For this reason, pre-
school-aged children, adolescents, and reproductive
age women are high-priority groups.
0003 Nearly one in three people living especially in
the developing world are affected by one or more
micronutrient deficiency. Iron and iodine deficiencies
are the most common and widespread nutritional
problems. About half the reproductive age women
in most of the developing countries suffer from
iron-deficiency anemia (IDA). Other high-risk groups
include preschool and school-age children and
adolescents. Iodine-deficiency disorders affect 20–
60% of people in different areas. Vitamin A defi-
ciency (VAD) has been widely recognized, though at
a lower clinical prevalence (around 1% in preschool
children). However, VAD at a subclinical level (based
on serum retinol assays) is thought to be around 10–
25%. This is associated with increased mortality and
morbidity risk in children and pregnant women.
There are other deficiencies that are certainly wide-
spread but far less well recognized, e.g., rickets in
young children, associated with calcium and vitamin
D deficiency. Dietary intake surveys and limited bio-
chemical indicators show that zinc deficiency is likely
as widespread as that of IDA. Selenium and other
micronutrients such as folate and vitamin E may
have major role in reducing risks of chronic disease
(e.g., cancers, heart diseases).
The major cause of micronutrient deficiencies is a 0004
lack of adequate intake of bioavailable minerals and
vitamins from the diet. This is exacerbated by the fact
that commonly consumed foods and beverages (such
as rice, wheat, corn, legumes, tea, and coffee) are high
in inhibitors and low in enhancers of micronutrient
absorption.
Role of Food Fortification
Micronutrient deficiencies can be prevented and even 0005
eliminated if populations consume adequate quan-
tities of the required micronutrients on a continuous
and ongoing basis. In addressing micronutrient
malnutrition in a country, a combination of interven-
tions involving promotion of a well-balanced diet,
improving food availability and micronutrient bio-
availability, and increasing food consumption, food
fortification, and pharmaceutical supplementation
need to be emphasized and implemented in a comple-
mentary manner. Among these options, food fortifi-
cation could play an important role to meet a
demonstrable need for a nutrient in the population
apparent from dietary, biochemical, or clinical
evidence.
Fortification is therefore one part of a range of 0006
measures that influence the quality of food that in-
clude improved agricultural practices, improved food
processing, and storage and consumer education to
adopt good food-preparation practices. The role of
foods and specific nutrients and nonnutrients in pro-
viding beneficial nutritional and physiological effects
is also gaining attention. As consumer interest in the
link between diet and health increases, there are many
tbl0001 Table 1 Recommended dietary allowances (RDAs) for some essential micronutrients

Minerals Fat-soluble vitamins Water-soluble vitamins

Category Age or Calcium Phos- Mag- Iron Zinc Iodine Sel- Vitamin Vitamin Vitamin Vitamin Thiamin Riboflavin Niacin Vitamin Folate Vitamin Vitamin
condition (mg) phorus nesium (mg) (mg) (mg) enium A D (mg)b E K (mg) (mg) (mg) (mg NE)d B6 (mg) (mg) C (mg) B12 (mg)
(mg) (mg) (mg) (mg RE)a (mg aTE)c

Infants 0–6 months 400 300 40 6 5 40 10 375 7.5 3 5 0.3 0.4 5 0.3 25 30 0.3
7–12 months 600 500 60 10 5 50 15 375 10 4 10 0.4 0.5 6 0.6 35 35 0.5
Children 1–3 years 800 800 80 10 10 70 20 400 10 6 15 0.7 0.8 9 1.0 50 40 0.7
4–7 years 800 800 120 10 10 90 20 500 10 7 20 0.9 1.1 12 1.1 75 45 1.0
8–11 years 800 800 170 10 10 120 30 700 10 7 30 1.0 1.2 13 1.4 100 45 1.4
Males 12–14 years 1200 1200 270 12 15 150 40 1000 10 10 45 1.3 1.5 17 1.7 150 50 2.0
15–18 years 1200 1200 400 12 15 150 50 1000 10 10 65 1.5 1.8 20 2.0 200 60 2.0
19–24 years 1200 1200 350 10 15 150 70 1000 10 10 70 1.5 1.7 19 2.0 200 60 2.0
25–50 years 800 800 350 10 15 150 70 1000 5 10 80 1.5 1.7 19 2.0 200 60 2.0
51þ years 800 800 350 10 15 150 70 1000 5 10 80 1.2 1.4 15 2.0 200 60 2.0
Females 12–14 years 1200 1200 280 15 12 150 45 800 10 8 45 1.1 1.3 15 1.4 150 50 2.0
15–18 years 1200 1200 300 15 12 150 50 800 10 8 55 1.1 1.3 15 1.5 180 60 2.0
19–24 years 1200 1200 280 15 12 150 55 800 10 8 60 1.1 1.3 15 1.6 180 60 2.0
25–50 years 800 800 280 15 12 150 55 800 5 8 65 1.1 1.3 15 1.6 180 60 2.0
51þ years 800 800 280 10 12 150 55 800 5 8 65 1.0 1.2 13 1.6 180 60 2.0
Pregnancy 1200 1200 320 30 15 175 65 800 10 10 65 1.5 1.6 17 2.2 400 70 2.2
Lactation 0–6 months 1200 1200 355 15 19 200 75 1300 10 12 65 1.6 1.8 20 2.1 280 95 2.6
7–12 months 1200 1200 340 15 16 200 75 1200 10 11 65 1.6 1.7 20 2.1 260 90 2.6
a
Retinol equivalents. 1 retinol equivalent ¼ 1 mg of retinol or 6 mg of b-carotene.
b
As cholecalciferol. 10 mg of cholecalciferol ¼ 400 IU of vitamin D.
c
1 mg of D-a tocopherol ¼ 1 a-TE.
d
1 NE (niacin equivalent) ¼ 1 mg of niacin or 60 mg of dietary tryptophan.
Source: National Research Council (1989) Subcommittee on the Tenth Edition of the Recommended Dietary Allowances. Washington, DC: National Academy Press.

opportunities for developing foods that can have
positive effects on health and performance.
0007 Food fortification involves the identification of
commonly eaten foods that can act as vehicles for
one or more micronutrients and lend themselves to
centralized processing on an economical scale.
0008 The Codex Alimentarius provides definitions for
terminology relating to the addition of nutrients to
foods. Fortification or enrichment means 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. Restoration refers to
compensation for unavoidable nutrient losses during
the course of good manufacturing practice in the
preparation and preservation of food or during
normal storage and handling procedures. In many
countries, there are requirements for the compulsory
addition of micronutrients such as iron, niacin, and
thiamine to bread and flour.
0009 Fortification, when imposed on existing food pat-
terns, does not necessitate changes in the customary
diet of the population and does not call for individual
compliance. Often, it can be dovetailed into existing
food production and distribution systems. For these
reasons, fortification can often be implemented and
yield results within 2–3 years and be sustained over a
long period of time. It can thus be the most cost-
effective means of overcoming micronutrient malnu-
trition.
Effectiveness of Fortification
0010 The concept of nutrient fortification of staple foods
was developed in the early part of this century as a
means of dealing with micronutrient and vitamin
deficiency diseases that were prevalent in Europe
and North America. Salt was iodized in Switzerland
in the early part of the century. Margarine fortified
with vitamin A was introduced in Denmark in 1918.
During the 1930s and 1940s, milk was fortified with
vitamin A, and flour was fortified with iron and B
vitamins in a number of European countries and in
North America. In developed countries, where there
is a high dependence on processed foods, and indus-
tries are streamlined and automated, food fortifica-
tion has played a major role in the health of the
populations at large over the last 40 years, and several
nutritional deficiencies have been eliminated. In
addition to the virtual elimination of VAD and iodine
deficiency disorders (IDD) and the substantial reduc-
tion of IDA, diseases as varied as xerophthalmia,
pellagra, beriberi, rickets, goiter, and ariboflavinosis
have essentially disappeared. Several studies have
FOOD FORTIFICATION 2615
demonstrated the effectiveness of food fortification
in eliminating micronutrient deficiencies. The current
low levels of iron deficiency in the USA are attribut-
able to fortified sources. Almost a quarter of iron
intake in the US diet comes from fortified sources,
much of that from flour products. In Canada, flour
fortification with B vitamins began in Newfoundland
in 1944. Within four years, deficiencies that were
earlier found in nearly 20% of the population had
dropped to negligible levels.
In the developing world, there has been a rapid 0011
growth in fortifying a wide range of foods. The
most successful global fortification experience is the
fortification of salt with iodine. Fortification of other
staple foods such as flour, oils, sugar, condiments,
dairy products, and a range of processed foods with
other micronutrients and vitamins are also increasing.
In Latin America, flour fortification is reaching sig-
nificant numbers of people, and sugar fortification
has taken hold in Central America. In Asia, the over-
all reach of fortified foods and its impact in eliminat-
ing micronutrient malnutrition is still small, but
growing.
In the last decade, the contribution of salt forti- 0012
fication towards the virtual elimination of IDD in
developing countries has been substantial. In most
nations where IDD was recognized as a public
health problem at the beginning of this decade, an
average of 60–70% of all salt for human and animal
use is now iodized. The stage is set for the global
elimination of iodine deficiency disorders globally
by 2005.
Food fortification has also played a major role in 0013
substantially reducing vitamin A and iron deficien-
cies. A national sugar fortification program in Guate-
mala has virtually eliminated VAD as a public health
problem. Flour fortification in Chile and Venezuela
are substantially improving iron status across all
sectors of the population. Today, in Latin America,
Asia, and Africa, consumers of fortified products as
varied as margarine, milk, noodles, and cornstarch
are substantially protected from a range of micro-
nutrient deficiencies.
Food fortification has to be an integral component 0014
of the overall strategy to eliminate micronutrient
malnutrition. It involves opening new communica-
tion channels among the public health community,
research institutions, government regulators, food
companies, and a variety of civic and consumer
organizations. The inputs from these groups could
result in a new alliance focused on accomplishing
national development through elimination of micro-
nutrient malnutrition. Food fortification should also
be the preferred option to reach preschoolers and
primary graders.
 2616 FOOD FORTIFICATION

Considerations for Planning a Food Key considerations for planning and implementing 0018

Fortification Intervention food fortification programs in countries are discussed

below.
0015 Food fortification involves the identification of com-
monly eaten foods in a country or region that can act
Selection of Food Vehicles
as vehicles for one or more micronutrients and lend
themselves to centralized processing on an econom- The selection of a suitable vehicle and a fortificant 0019

ical scale. In developed countries, a range of cereals
and cereal products, dairy products, processed foods
and beverages are fortified. In most developing coun-
tries, staple foods and condiments are the obvious
choice for fortification, given their consistent con-
sumption by large sections of the population. In
such situations, the choice of vehicles at the present
time is limited to a handful of foods and condiments:
cereals, oils and fats, sugar, salt, and sauces.
0016 Fortification of foods is aimed to provide meaning-
ful levels of the nutrient at normal consumption of the
food vehicle. Variations in food consumption may
affect the safety of those at the higher end of the scale
and the level of impact for those at the lower end. They
should also consider prorated intakes by young chil-
dren to ensure efficacious and safe dosages. Food
fortification also requires careful attention to food
regulations and labeling, and a careful assessment of
the technical and analytical limitations for compli-
ance with label declarations. The Codex Alimentarius
that deliver the micronutrient in the right amounts
consistent to an entire population is extremely
rare. Salt iodization is one example of successful
large-scale fortification in the developing world –
the primary reason being the simple and low-cost
technology and the narrow variation in salt consump-
tion within a given region or population. There exist
other opportunities for single and multiple fortifica-
tion of several commonly eaten foods such as wheat
and wheat products, corn, rice, milk and milk
products, cooking oils, sugar, and condiments. As
processed foods gain popularity in the developing
world, with an increasing market outreach, they
offer new channels for micronutrient delivery. The
decision to use a particular food or beverage must
be based on scientific data. Well-designed market
research, which includes dietary surveys and habits
and practices, should be used as a tool in identifying
the commonly consumed foods and beverages.
Potential food vehicles could be visualized as a 0020

has adopted a number of basic principles set out in
Table 2 for the addition of nutrients to foods.
0017 Infants and children under the age of 24 months
consume a different dietary pattern than do older
individuals. There are no major differences in con-
sumption among children aged 2 years and older.
Where there are few centrally processed complemen-
tary foods, and consumption of such foods is infre-
quent and rare, careful research is needed on the best
ways to address micronutrient problems of infants.
three-tiered pyramid (Figure 1). Staple foods such as
sugar, cereals, grains, fats, and oils form the base;
basic foods such as breads and biscuits, packaged
cereals and flours, and dairy products are in the
middle; and value-added foods such as condiments,
snacks, candies, convenience and ready-to-eat foods
are at the top. Fortifying less expensive staple foods at
the base of the pyramid results in broader dissemin-
ation of micronutrients throughout the population.
Also, since basic and value-added foods are processed

tbl0002 Table 2 General principles for the addition of nutrients to foods

1. The essential nutrient should be present at a level that will not result in either an excessive or an insignificant intake of the added
essential nutrient considering amounts from other sources in the diet
2. The addition of an essential nutrient to a food should not result in an adverse effect on the metabolism of any other nutrient.
3. The essential nutrient should be sufficiently stable in the food under customary conditions of packaging, storage, distribution, and
use.
4. The essential nutrient should be biologically available from the food.
5. The essential nutrient should not impart undesirable characteristics to the food (e.g., color, taste, flavor, texture, cooking
properties) and should not unduly shorten the shelf-life.
6. Technology and processing facilities should be available to permit the addition of the essential nutrient in a satisfactory manner.
7. Addition of essential nutrients to foods should not be used to mislead or deceive the consumer as to the nutritional merit of the food.
8. The additional cost should be reasonable for the intended consumer.
9. Methods of measuring, controlling and/or enforcing the levels of added essential nutrients in foods should be available.
10. When provision is made in food standards, regulations, or guidelines for the addition of essential nutrients to foods, specific
provisions should include identifying the essential nutrients to be considered or to be required and the levels at which they should
be present in the food to achieve their intended purpose

Source: Codex Alimentarius Commission (1994) Codex Alimentarius. General Principles for the Addition of Essential Nutrients to Foods, vol. 4. CAC/GL 09-
1987. Rome: Food and Agriculture Organization.

Value-added
foods
e.g. condiments, beverages
convenience foods, candies
Basic foods
e.g. breads, biscuits, packaged
cereals, dairy products
Staple foods
e.g. whole grain & milled cereals,
oils & fats, sugar, salt
fig0001 Figure 1 Food-product pyramid.
from staple commodities, fortifying foods at the base
of the pyramid results in fortifying products through-
out the food chain.
0021 In many countries, a flexible approach using a
variety of vehicles each fortified to a specified propor-
tion of recommended dietary intake (RDI) may offer
an effective option. If consumption of a particular
vehicle is consistent in some groups but only sporadic
in others, fortifying several vehicles will likely provide
complementary coverage. When considering a multi-
faceted approach, each food vehicle offers specific
opportunities and constraints:
0022 Cereals Cereal grain products such as rice, corn,
and wheat flour constitute an important calorie and
protein source for many populations. They have
proven to be good vehicles in several developed and
developing countries, but their application may be
limited where cereals foods are often eaten where
they are grown and processed at the community level.
0023 Fat and oils Cooking fats and oils may offer an
option to deliver a portion of the recommended
dietary allowance (RDA), particularly the fat-soluble
vitamins such as vitamin A. They have an advantage
in that they are often centrally refined and packed.
0024 Dairy products Milk may offer an option where
centralized dairy processing exists.
0025 Condiments Sugar, spices, starches and sauces are
attractive carriers. Some are processed centrally and
consumed in regular quantities.
0026 Value-added products In developed countries such
as the USA, fortification of snack foods has been
recommended as an appropriate public health
FOOD FORTIFICATION 2617
measure, given the increasing percentage of dietary
energy that the population derives from snack foods.
In developing countries, the most vulnerable popula-
tions consume these higher-priced products only spor-
adically. However, consumer awareness, technical
breakthroughs, and marketing innovations often
emerge from the development of fortified value-
added products.
When no universally consumed vehicle is available 0027
in a country, the fortification of a number of foods
offers several key strategic advantages. When a var-
iety of food sectors are engaged, no single industry
can claim unfair treatment. When a variety of foods
are fortified, each with a lesser proportion of RDI, the
theoretical possibility of consuming dangerous levels
of a micronutrient through excess consumption of a
single food becomes more remote.
Technologies
Depending on the manner in which foods are pro- 0028
cessed, different methods for addition of micronu-
trients have been developed:
. Dry mixing for cereal flours and their products, 0029
powder milk, powder beverages.
. Dissolution in water for liquid milk, drinks, fruit 0030
juices and in the water to be used for making bread
pastas cookies.
. Spraying as in iodization of salt and cornflakes, 0031
where the vitamins do not support the cooking or
extrusion step.
. Dissolution in oil for the lipo-soluble vitamins for 0032
enrichment of oily products like margarine.
. Adhesion for sugar fortification where the vitamin 0033
A in powder form is adhered to the crystals surface
by a vegetable oil.
. Coating as in rice where the vitamins sprayed over 0034
the grain must be coated in order to avoid the losses
when washing the grains before cooking.
. Extrusion of a blend of rice flour with micro- 0035
nutrients and stabilizers to provide a premix grains
that can be blended with rice after milling.
Research and development efforts have enhanced ef-
fectiveness of fortification technology. Better refining
procedures and packaging have significantly im-
proved the stability of iodine compounds in salt. In
the case of iron, stabilizers and absorption enhancers
are added along with the fortificant to retain it in
an absorbable form or improve absorption. The
structure of the iron or iron compounds has been
modified to improve absorption. In the case of vita-
min A, work is ongoing to retard the loss of potency
on storage through addition of antioxidants and
other stabilizers. In all these cases, there is scope for
further improvement and refinement for better
 2618 FOOD FORTIFICATION
product stability, absorption, and lower cost, and
development efforts need to continue.
Regulations, Guidelines, and Standards for
Fortification
0036 The objective of the regulations and guidelines should
be (1) to protect the population who buy and con-
sume the product and (2) establish standards and
guidelines to which all producers of the fortified
products should conform.
0037 The regulation and guidelines should include the
following:
0038 A rationale for fortification The decision to fortify a
product with particular nutrient has to be based on
scientific data obtained through dietary surveys and
biochemical and/or clinical studies.
0039 Recommended minimum and maximum level(s) of
nutrient added per serving The level of the fortifi-
cant added should not be too low to have little or no
impact on the nutrition status of the population. At
the same time, the level added should not be in excess
to cause toxicity.
0040 Establishing RDA This is essential as a reference for
fortification and in communicating the amount of the
nutrients per serving to the population that consume
the fortified product.
0041 Establishing labeling standards The goal is to detail
only relevant information.
0042 Establishing guidelines for making nutritional and
health claims Claims made on the nutritional and
health benefits of the product should be supported
by scientific data.
0043 Establishing a monitoring and surveillance
system For the regulations and guidelines to be
effective, there should be a monitoring and surveil-
lance system established.
Quality Assurance
0044 The success of producing and distributing a micronu-
trient-fortified product is dependent on the placement
of a quality assurance program that includes the
following:
0045 Finished product specification and description In
order to build quality into the fortified product, the
specification and description of the finished product
must be established prior to its manufacture. The
manufacturing process should be detailed in written
operating procedures. Based on the claim to be made,
the type and dosage of the micronutrients and the
form and source of fortificants are specified.
Raw materials The quality of the raw materials for 0046
both the product and packaging play an important
role in the quality of the final micronutrient fortified
product. The micronutrient fortificants should meet
established specifications. In addition, premix pur-
chases are made from approved suppliers that follow
good manufacturing practices (GMP). Once received,
the fortificants are recorded and stored as specified in
an appropriate condition.
Production and Packaging A quality product is en- 0047
sured by following GMP. The micronutrient sources
are added into the product formulation by using
already-specified procedure and equipment. The
amount of each fortificant added is recorded. Finally,
the amount in the finished product is verified by using
a validated analytical method.
Release of finished product The product released 0048
for distribution should meet all final product specifi-
cations. This includes the safety of the product and
the level of the micronutrients claimed. There should
be a system for (1) monitoring and correcting devi-
ations from specification and (2) identifying the prod-
uct in case there is a complaint from the consumer.
Documentation Accurate recording is essential for 0049
(1) identifying and correcting deviations, (2) recalling
a product with serious problems, and (3) making an
improvement on the quality of the product.
Training All personnel involved in the development, 0050
manufacturing, packing, and storage of the fortified
product should be trained in quality assurance.
Advocacy and Social Communications
An effective communications campaign supported by 0051
the government should necessarily accompany any
major fortification effort in order to gain the under-
standing and support of key sectors from policy-
makers and legislators to medical professionals,
health workers and consumer groups.
Monitoring and Evaluation
As micronutrient fortification programs expand in 0052
countries around the world, the need to monitor the
quality of the fortified food (in terms of its micro-
nutrient content) and evaluate its contribution to the
alleviation of micronutrient deficiencies will increase.
Monitoring activities should ensure that a fortified
product contains a sufficient amount of the micronu-
trient and that it reaches the target population. The

indicators used to monitor fortification efforts reflect
the need to determine the quality and safety of the
products and their availability to the populations at
greatest risk. Monitoring is carried out at various
levels – production or importation, wholesale and
retail and household. The production and import-
ation levels are the most important point for monitor-
ing the fortification activity.
0053 Monitoring is vitally important to the success of a
fortification program for the following reasons:
0054 To improve program effectiveness A fortification
program can be effective only if a high-quality forti-
fied is produced, delivered, accepted, and consumed
by the target population on a continuous and self-
sustaining basis.
0055 To ensure compliance with government
standards Monitoring systems will provide infor-
mation on the extent to which the product conforms
to national standards at points of production and
consumption. This information is needed to enforce
compliance through regulation and encourage volun-
tary corrective action by the producer.
0056 To identify problem points in the fortification
process As food moves from the factory to the
household, it generally goes first to distributors,
then to retail outlets. In some cases, foods are fortified
outside the country and imported for eventual con-
sumption. Monitoring must occur at various critical
points starting at the production level and ending at
the household level, where the fortified food is stored,
prepared, and consumed.
0057 To ensure safety Effective monitoring will ensure
that the micronutrient content of the fortified food
is within the desired range.
0058 As a final indication of effectiveness, an impact
evaluation conducted after 2 or 3 years will determine
whether the micronutrients are absorbed well and are
preventing recurrences of micronutrient deficiencies
in the population.
Progress in Food Fortification
0059 Key global developments to address specific micronu-
trient deficiencies through food fortification are sum-
marized below.
0060 Iodine Over the past 60 years, a variety of vehicles
including bread, flour, sugar, and salt have been
proposed as carriers for iodine. Among these, salt
iodization has witnessed a remarkable growth in ap-
plication globally over the past decade. A significant
proportion of the populations in over 110 countries
FOOD FORTIFICATION 2619
have access to iodized salt. Once established in a
country, salt iodization is a permanent and long-
term solution to the problem of iodine deficiency.
Depending upon per-capita salt consumption and an-
ticipated iodine losses between production and con-
sumption, iodine dosage ranges from 20 to 100 mg
per kilogram of salt. These losses are dependent upon
the quality of salt and packaging. Toxicity issues are
negligible, and cost considerations fairly small. Al-
though there is considerable progress in streamlining
control programs through salt iodization in several
countries, producer compliance, quality assurance,
logistic problems, and bottlenecks do remain. The
challenge is to systematically identify and tackle
these constraints through effective advocacy, social
communications, monitoring of salt iodine levels,
regulation, and enforcement. In many developing
countries, salt iodization is the first large-scale experi-
ence in national fortification of a commodity. It has
provided valuable lessons in collaboration between
government, industry, nongovernmental organiza-
tions, the media, and other sectors. It has also given
insights into building and sustaining an intervention
politically, technically, financially, and culturally.
Iron Although iron has potential for use in more 0061
food vehicles than iodine or Vitamin A, fortification
with iron is technically more difficult than with other
nutrients, since iron reacts with several food ingredi-
ents. There are a number of iron compounds that are
approved for food fortification. The greatest chal-
lenge with iron is to identify a form that is adequately
absorbed and yet does not alter the appearance or
taste of the food vehicle. The buff-colored, insoluble
iron phosphate compounds are stable under a variety
of storage conditions but are poorly absorbed. The
soluble iron salts like ferrous sulfate are well
absorbed but easily discolor by reacting with food
ingredients. In addition to the general fortification
criteria, iron fortification needs to take into account
certain specific considerations:
1. The vehicle should be a component of all meals, 0062
because absorption varies inversely with the iron
content of the meal.
2. It should not require prolonged storage particu- 0063
larly under hot and humid climatic conditions,
since this could cause organoleptic problems.
3. Vehicles that are dark in color or have a strong 0064
taste or odor permit the use of more reactive iron
compounds.
4. Segregation of iron should not occur during 0065
mixing or storage.
Reducing the global prevalence of iron deficiency
anemia will require the use of several alternative
 2620 FOOD FORTIFICATION
fortification compounds and food vehicles,
depending upon the local dietary patterns. Some
promising possibilities are:
0066 Wheat/corn flour and bakery products In developed
countries like the USA, Sweden, and Canada, these
foods have had significant success as vehicles for iron.
Flour fortification ensures an even meal distribution
of the added iron and provides a reasonably constant
iron supply to each individual. More recently, all corn
and wheat flour in Venezuela was fortified with
iron (mixture of ferrous fumarate and reduced iron),
vitamin A, and B vitamins.
0067 Condiments In Thailand, fish sauce, which is con-
sumed in many parts of the country, has been tested as
a vehicle for iron [in the form of sodium iron ethyl-
enediaminetetraacetic acid (EDTA) ] and has shown a
good hemoglobin response. Fish sauce and fish pastes
have also been tried as vehicles in the Philippines
and Vietnam. Curry powder used by an Indian popu-
lation in South Africa has been fortified with sodium
iron EDTA with successful results. In China, the feasi-
bility of using soy sauce as a carrier for iron is being
examined.
0068 Processed foods There is a growing trend in several
developing countries increasingly to use processed
foods such as noodles, cereals, and soup cubes.
Weaning foods for children are also becoming popu-
lar. Elemental iron of small particle size is being used
for the fortification of processed cereals in several
developed countries. In Mexico, a chocolate milk
powder is fortified with iron. In Tanzania, a fortified
orange beverage drink has proved effective in improv-
ing the iron and vitamin A status among school
children and pregnant mothers.
0069 Salt Recent work has focused on developing a for-
mulation that would permit the addition of both
iodine and iron. (The acidic medium in which the
iron compound is stable causes the rapid oxidation
of iodide/iodate to free iodine, which vaporizes
and is lost). A promising approach uses dextrin-
encapsulated potassium iodide/iodate mixed with
encapsulated ferrous fumarate to provide a barrier
between the iron and iodine and improving stability.
The successful testing and large-scale application of
available technology for the double fortification of
salt could represent a major breakthrough for com-
bined iron and iodine delivery.
0070 Zinc Several zinc compounds are available for food
fortification ranging in solubility from very soluble
(sulfate and chloride), freely soluble (acetate), to
almost insoluble (carbonate and oxide). The soluble
compounds, especially sulfate and chloride, are most
preferred as fortificants. Unlike iron, zinc does not
undergo oxidation–reduction. As a result, it does
not cause the development of undesirable color and/
or flavor when added to foods and beverages. How-
ever, like iron, it does cause metallic aftertaste and
astringency. Currently, only infant formulas, cereal
products (especially infant cereals), and dietetic prod-
ucts (e.g., products used for enteral feeding) are forti-
fied with zinc.
Calcium Foods normally fortified with calcium in- 0071
clude cereals and beverages, foods sold as a replace-
ment to milk/yogurt, e.g., soy milk/yogurt, infant
formula, weaning foods, enteral foods, slimming
foods, and meal replacements. Flour is one of the
best examples of fortification of cereal products. A
range of breakfast cereals, rice, and corn products are
also fortified with calcium in a few countries. More
recently, orange juice and concentrates have been
fortified with calcium. The compounds commonly
used for fortification include carbonate, phosphate/
lactate, citrate malate, or gluconate.
Vitamins A and D Vitamin A has been successfully 0072
added to foods such as milk (various forms of liquid
and dry milk), butter, cheese, flour, bread and cereal
product, snacks, and beverages. The most widespread
application is in oils or fats that are dietary ingredi-
ents of most populations. It is essential that foods
fortified with vitamin A are sealed in opaque or
dark-colored glass containers with closures to elimin-
ate the effect of light, a stimulant to oxidative pro-
cesses. Edible antioxidants may also be added to
protect both the oil and the added vitamin A from
oxidation. Fortification of margarine is widely prac-
ticed (at levels of 20 000–50 000 IU kg1) to equal or
exceed the average levels of this nutrient in butter.
Often, vitamins D and E are also added. If synthetic
b-carotene is also to be used, both color and vitamin
A can be added simultaneously. When fat is removed
from whole fluid milk, all fat-soluble vitamins, in-
cluding vitamin A, are removed. All skim milk or
low-fat liquid or dry milk products should have vita-
min A added and, if given to infants, should probably
have vitamins D, E, and possibly C as well. Sugar is
another vehicle for vitamin A in Central American
countries like Costa Rica, Guatemala, Panama, and
Honduras.
B vitamins and folate Thiamine, riboflavin and 0073
niacin have been traditionally added to wheat flour
in many countries for several decades. As a result,
several vitamin B deficiency conditions like beriberi

and pellagra have been eliminated. Most recently, the
addition of folate to grain products was made man-
datory to reduce the prevalence of neural-tube defects
and other congenital abnormalities in children caused
by folate deficiency in the mothers during pregnancy.
See also: Calcium: Properties and Determination;
Carotenoids: Occurrence, Properties, and
Determination; Cholecalciferol: Properties and
Determination; Iodine: Properties and Determination;
Iodine-deficiency Disorders; Niacin: Properties and
Determination; Quality Assurance and Quality Control;
Riboflavin: Properties and Determination; Thiamin:
Properties and Determination; Vitamins: Overview; Zinc:
Properties and Determination
Further Reading
Bauernfeind JC and Lachance PA (eds) (1991) Nutrition
Addition to Foods; Nutritional, Technological and Regu-
latory Aspects. Trumbull, CT: Food and Nutrition Press.
Clydesdale FM and Wiemer KL (eds) (1985) Iron Fortifica-
tion of Foods. London: Academic Press.
Codex Alimentarius Commission (1994) Codex Alimen-
tarius. General Principles for the Addition of Essential
Food Intake See Dietary Surveys: Measurement of Food Intake; Surveys of National Food Intake; Surveys
of Food Intakes in Groups and Individuals
FOOD INTOLERANCE
Contents
Types
Food Allergies
Milk Allergy
Lactose Intolerance
Elimination Diets
Types
J Gray, Guildford, Surrey, UK
W Chan, London, UK
Copyright 2003, Elsevier Science Ltd. All Rights Reserved.
Introduction
0001 The umbrella term ‘adverse reactions to food’ has
been adopted to describe a range of different types
FOOD INTOLERANCE/Types 2621
Nutrients to Foods, vol. 4. CAC/GL 09-1987. Rome:
Food and Agriculture Organization.
Food Fortification to End Micronutrient Malnutrition.
State of the Art (1998) Proceedings of the Satellite Con-
ference of the XVI International Congress of Nutrition.
Ottawa: The Micronutrient Initiative.
Hurrell RH (ed.) (1999) The Mineral Fortification of
Foods. Leatherhead, UK: Leatherhead International Ltd.
Lotfi ML, Venkatesh Mannar MG, Merx RH and Naber
van den Heuvel P (1996) Micronutrient Fortification of
Foods. Current Practices, Research and Opportunities.
Ottawa: The Micronutrient Initiative, Ottawa &
Wageningen: International Agricultural Centre.
Micronutrient Fortification of Foods. Current Practices, Re-
search and Opportunities. Ottawa: The Micronutrient
Initiative: Ottawa, Canada & Wageningen, The Nether-
lands: International Agricultural Centre.
Mason JB, Lotfi M, Dalmiya N, Sethuraman K and Deitch-
ler M (2001) The Micronutrient Report. The Micro-
nutrient Initiative.
Nestel P (1993) Food in Fortification Developing Coun-
tries. Washington, DC: USAID/Vital.
Richardson DP (1997) The addition of nutrients to foods.
Proceedings of the Nutrition Society 56: 807–825.
of responses to food, in particular food intolerance,
food aversion, and food poisoning (Table 1). One
way of distinguishing food intolerance and food
poisoning is to consider the former as a defect in the
individual and the latter as that of the food. The
mechanisms underlying food intolerance are numer-
ous, complex, and incompletely understood. It is cer-
tain that far fewer reactions are due to true allergy
(involving the immune system) than is commonly
believed. This article discusses the definitions and