FAQs - Health Impact of Fortification

Q: What vitamins and minerals are in cereal grains naturally?

Wheat, maize, and rice are natural sources of the following minerals: calcium, phosphorus, zinc, iron, and copper.

They are also natural sources of the following B vitamins: folate (B9), thiamin (B1), riboflavin (B2), niacin (B3), pyridoxine (B6), and biotin (B7).

Source: Bauernfeind and DeRitter, Nutrient Additions to Food

Q: Why are vitamins and minerals added to cereal grains during fortification?

Nutrients in cereal grains are mainly in the outer layers, and these are discarded as the grain is milled. Fortifying returns the lost nutrients, but simply restoring the nutrients may not be enough to make a health impact in populations where deficiencies have been identified. Appropriately fortifying grains with additional amounts of vitamins and minerals can improve public health.

Q: What nutrients are added to flour and rice in fortification?

This is different in every country. Global guidelines are available for wheat fortification, but each country is encouraged to consider its unique nutritional needs to establish fortification standards. Another consideration in setting standards is whether other staple foods are fortified. For example, if a country fortifies cooking oil with vitamin A, it might not include vitamin A in fortified wheat flour.

The most common nutrients added to flour are iron and folic acid, a form of vitamin B9. Other vitamins commonly added to flour are thiamin, riboflavin, and niacin. Likewise, rice is commonly fortified with iron and most of the B vitamins. Riboflavin (vitamin B2) is usually not added to rice because its orange color changes the appearance of rice.

The following table shows the types of common nutrients and their compound form that are used in fortification of cereal grains:

• Vitamin A: Vitamin A Palmitate water dispersible, spray dried stabilized; Vitamin A Acetate water dispersible spray dried, stabilized
• Vitamin B group: B1 Thiamine Mononitrate, B2 Riboflavin Hydrochloride, B3 Niacin or Nicotinamide, B5 Calcium Panthothenate, B6 Pyridoxine hydrochloride, B9 Folic acid, B12 Cyanocobalamin 0.1% or 1% spray dried
• Vitamin D: D3 Cholecalciferol
• Calcium: Calcium Carbonate, Calcium Sulphate
• Iron: For flours: Sodium Iron EDTA, Ferrous Sulfate, Ferrous Fumarate, Electrolytic Iron powder For rice: Ferric pyrophosphate
• Zinc: Zinc Oxide, Zinc Sulphate

Q: How much of each nutrient is used in fortification?

This is different in every country. Some factors to consider in determining the amount of each nutrient to include in fortification are:

• Vitamin and mineral deficiency among the population
• Average flour/rice consumption
• The body's ability to absorb the vitamin or mineral compound
• Effect on the food’s sensory properties
• Ongoing cost to buy premix of vitamins and minerals for fortification

Q: Does flour and rice fortification help reduce vitamin and mineral deficiencies in the general population?

Fortifying flour with iron has been shown to improve iron status among specific populations in at least four countries: China, Iran, Venezuela, and Fiji. Many countries with fortification programs, however, do not measure iron status before and after fortification. Eight sub-national studies have found that fortifying flour with folic acid reduced the incidence of neural tube birth defects such as spina bifida by 31% to 78%.

Several controlled research studies conducted in children and young women have demonstrated that regular consumption of rice fortified with adequate levels of easily absorbed nutrients results in a significant reduction in the prevalence of micronutrient deficiencies.

Q: Is it safe for children and pregnant/lactating women to eat fortified foods every day?

Children and pregnant and lactating women especially benefit from consuming fortified foods as they require high levels of vitamins and minerals to support physical growth and the development of new tissues. When many fortified foods reach the same population, a country may want to conduct a comprehensive analysis of food consumption to ensure that the population is not consuming excessive levels of nutrients.

For example, United States residents have access to folic acid in foods made with enriched flour, breakfast cereals that are voluntarily fortified, and through easily-accessible vitamin supplements. Yet a study found that only 2.7% of the adult population consumed excessive levels of folic acid, and only people who took high-dose supplements reach the high levels.

Q: Are there any known side effects to consuming fortified rice, wheat, or maize flour?

No side effects on health have been reported in the studies published on fortified rice or wheat and maize flour.

Q: How fast can health effects of consuming fortified food be expected?

When appropriate levels of easily absorbed iron are used, fortification can impact iron status within 12 months after the program is fully implemented if the vulnerable population consumes fortified products daily. As it takes time for programs to be fully operational, fortification leaders estimate it may be three years between fortification’s initiation and a nutritional impact on iron status.

With folic acid, changes in folate status may be observed within 3 to 4 months after fortification is fully implemented. It will take at least 12 months to see an impact on neural tube defects because women need to be consuming folic acid at the time they conceive to prevent these birth defects.