Why Fortify?
Adults
Photo: RTI
Nutrition increases productivity
Ages 15 to 49 years are considered reproductive years. For both men and women this age, proper nutrition is essential for physical productivity. Deficiencies of six nutrients can lead to anemia which causes debilitating fatigue.
Food fortification is one of six key actions to reduce anemia. UNICEF also recommends fortification as one way to prevent vitamin and mineral deficiencies. A review of anemia data from 12 countries that fortified flour and 20 countries that did not showed a 2.4% yearly decrease in anemia in countries that did fortify. The countries that did not fortify flour showed no reduction in anemia prevalence over time.
Women who are not planning a pregnancy are likely not taking folic acid (vitamin B9) supplements, and most people do not consume the recommended equivalent of 400 micrograms of folic acid from unfortified food. In contrast, women who regularly consume foods fortified with folic acid increase their intake of this essential nutrient and are less likely to have an infant with a brain or spine birth defect.
Nutritional Needs
Both men and women need iron, riboflavin, folic acid, zinc, vitamin A, and vitamin B12 to prevent specific types of anemia. Zinc and vitamin A also strengthen immune systems. Riboflavin helps with the metabolism of fats, carbohydrates, and proteins. Vitamin B12 maintains the functions of the brain and nervous system.
Consequences of Deficiencies
Anemia
Defined as low hemoglobin, anemia's symptoms include lethargy and decreased productivity. It also leads to complications in pregnancy, low-birth weight infants, and maternal deaths.
Anemia is estimated to contribute to:
17% lower productivity in heavy manual labor
5% lower productivity in other manual labor [1].
Studies throughout the years have confirmed the link between iron status and productivity. Three examples are:
In the 1970s, the quantity of tea picked by workers in Sri Lanka was evaluated after one month of iron treatment. The overall increase in tea picked per day that could be attributed to iron treatment was 0.3 kilograms, which was significantly greater than the quantity of tea picked by those who received placebos [2].
In the early 1990s, the work productivity of 80 iron-deficient women was studied at a cotton mill in Beijing, China. Their work pace was determined by a machine and was constant throughout the study. Women who were treated with iron were able to perform their work with less cardiovascular stress and less exertion [3].
A 2001 paper conducted a systematic review of research literature about the relationship between iron deficiency anemia and work capacity. The authors found that the effect of iron-deficiency anemia on work capacity justifies interventions to improve iron status [4].
In children, iron deficiency limits physical growth and mental development, and these losses are never recovered. Children who do not reach their full physical and academic potential will have limited future opportunities.
Brain and Spine Birth Defects
Folic acid (vitamin B9) is included in fortification to help prevent brain and spine birth defects, also known as neural tube defects. Spina bifida is a common example of these congenital conditions. Spina bifida cannot be cured, and it leads to some level of paralysis and bowel and bladder control problems.
Adults who care for children with spina bifida spend time making medical appointments, taking children for treatment, and helping children with many daily activities such as toileting and mobility [5]. Adults with spina bifida are very often independent and productive, but they usually require ongoing and often intensive medical care [5].
A study of 88 people in Germany with spina bifida found that physiotherapy was the most used healthcare resource, and more than half the study participants used a wheelchair [6]. The authors concluded that their care givers "might have to either adjust their careers overall or adjust their working schedule, resulting in productivity losses" [6].
The severe brain and spine birth defects that can be mostly prevented with adequate folic acid intake are spina bifida, anencephaly, and encephalocele.
Extent of the Problem
Anemia affects an estimated 496.3 million non-pregnant women and 32.4 million pregnant women between the ages of 15 and 49 years. Iron deficiency causes about half the anemia among women globally, though this varies by region.
About 230,000 brain and spine birth defects could be prevented every year if women had adequate intake of folic acid before and immediately after conception.
Sustainable Development Goals
Nutrition during the reproductive years addresses several Sustainable Development Goals.
Increased productivity helps lower poverty (goal 1) and contributes to economic growth (goal 8).
Improved nutrition contributes to zero hunger (goal 2) and good health and well-being (goal 3).
Since women are more prone to anemia than men, reducing the prevalence of anemia is a step toward gender equality (goal 5)
Photo: Adam Cohn/Flickr
Nutrition is needed throughout the aging process
Physical changes, medications, hospitalizations, and social factors can put older adults at risk of malnutrition which makes other health problems worse. Consequently, fortifying flour and rice is as important for the aging population as it is for children and for women who may become pregnant.
An aging population has many implications for a country’s economy and health system. Aging also increases the individual's chance of having a chronic disease such as heart disease, diabetes, and osteoporosis. Proper nutrition plays a role in preventing diseases, and good nutrition contributes to quality of life and lessens the disease’s effects.
Iron and Zinc
The recommended daily intake (RDI) of iron and zinc varies as people age, but both minerals are needed throughout the lifespan. How much iron a person needs daily depends partly on the source of their iron intake. If the iron is highly bioavailable, meaning that it is easy for the body to absorb, less iron is needed than if it has low bioavailability. Animal foods have the most bioavailable forms of iron. People who eat limited amounts of animal foods may need more iron than they consume from unfortified foods. Iron is needed for productivity and zinc is needed for healthy immune systems. Both iron and zinc deficiencies can cause anemia.
Folic Acid (Vitamin B9)
The RDI of folic acid (vitamin B9) is 400 micrograms of folic acid for all adult men and women. This amount of vitamin B9 is nearly impossible to consume daily from unfortified food alone. This nutrient helps people produce and maintain healthy cells and prevent anemia from vitamin B9 deficiency.
One neurologist’s research shows that in older adults, “vitamin B9 deficiency contributes to aging brain processes, increases the risk of Alzheimer's disease and vascular dementia and, if critically severe, can lead to a reversible dementia.”
Also, people need vitamins B9, B6 and B12 to lower homocysteine levels. This is important because elevated homocysteine levels are associated with dementia, heart disease, stroke, and osteoporosis.
Vitamin B12
Vitamin B12 maintains functions of the brain and nervous system. For men and for women who are not pregnant or lactating, the need for vitamin B12 remains constant through adulthood. Some people have trouble absorbing vitamin B12. This nutrient is found in animal-source foods, and vitamin B12 deficiency can also cause anemia.
Calcium
Calcium is needed for protecting bones, transmitting nerve messages, enhancing muscle function, and clotting blood. The RDI for calcium remains at 1,300 micrograms per day for women from age 51 years through the rest of their lives. For men, the RDI increases from 1,000 micrograms per day from 19 to 65 years to 1,300 micrograms per day after 65 years.
Vitamin A
For adults, vitamin A is important for normal vision, immunity, reproduction, and proper functioning of the heart, lungs, kidneys, and other organs. Though too much vitamin A can be dangerous, the daily “recommended safe intake” for women increases from 500 micrograms of retinol equivalents per day from 50 to 65 years to 600 micrograms of retinol equivalents per day after 65 years. The recommended safe intake for men remains at 600 micrograms of retinol equivalents from age 19 years through the rest of the life span. Cooking oil is often fortified with vitamin A.
Vitamin B6
Vitamin B6 facilitates enzyme reactions involved in metabolism and assists with immune function. It is also one of the vitamins that prevents the accumulation of homocysteine. A woman’s RDI of vitamin B6 remains at 1.5 micrograms per day from 50 years of age throughout the rest of her life. For men, the RDI after 50 is to 1.7 micrograms per day. Poultry, fish, potatoes, and non-citric fruit are good sources of vitamin B6. People in countries where diverse foods are not accessible or affordable may have vitamin B6 deficiency and would benefit from foods being fortified with vitamin B6.
Vitamin D
Vitamin D is sometimes called the sunshine vitamin because people produce it when their skin is exposed to sunlight. People who mostly stay indoors, including some elderly people with limited mobility, are more likely to develop vitamin D deficiency. Women’s RDI for vitamin D increases from 10 micrograms per day from 50 to 65 years to 15 micrograms per day after 65 years. For men, the RDI for vitamin D increases from 5 micrograms per day from 19 to 50 years to 15 micrograms per day after 50 years.
Vitamin D is essential for bone health because it helps people absorb calcium. As a result, vitamin D deficiency in adults contributes to osteoporosis, which is marked by weak and brittle bones. This often leads to broken bones, most often of the wrist, spine, and hip. Women of Asian and Caucasian descent are more prone to osteoporosis than other ethnic groups, according to the International Osteoporosis Foundation.
To see which nutrients a specific country requires in mandates for wheat flour, maize flour, or rice fortification, see its country profile.
Resources
[1] Horton, S., and Ross, J, The Economics of Iron Deficiency. Food Policy. 2003, 28: 51-75. Also see corrigendum.
[2] Edgerton, V.R., et al., Iron-deficiency Anaemia and Its Effect on Worker Productivity and Activity Patterns. British Medical Journal. 1979.
[3] Li, Ruowei, et al., Functional Consequences of Iron Supplementation in Iron-deficient Female Cotton Mill Workers in Beijing, China. American Journal of Clinical Nutrition, 1994.
[4] Haas, Jere D., and Brownlie, Thomas IV., Iron Deficiency and Reduced Work Capacity: A Critical Review of the Research to Determine a Causal Relationship. American Society for Nutritional Sciences. 2001.
[5] Gross, Scott, et al., c., Impact of Spina Bifida on Parental Caregivers: Findings from a Survey of Arkansas Families. Journal of Child and Family Studies, 2009.
[6] Van Nooton, F.E., et al., Resource Utilization and Productivity Loss in Persons with Spina Bifida - An Observational Study of Patients in a Tertiary Urology Clinic in Germany. European Journal of Neurology, 2014.