Why Fortify?

Save Lives

Countries add nutrients to flour and rice to help people and nations thrive. Iron, zinc, folic acid, and other B vitamins are commonly added to prevent anemia from nutritional deficiencies and reduce the risk of infants with severe brain and spine birth defects known as neural tube defects.

Fortification is a safe nutrition intervention proven to benefit individuals at every point in life—from conception to aging. Also, breastfeeding mothers, adolescents, and adults in their reproductive years need the nutrients included in micronutrient fortified foods.

Nationally, fortification improves productivity and reduces healthcare expenditures. Globally, fortification addresses several of the Sustainable Development Goals and can restore nutrients lost in crops as a result of climate change.

A Matter of Life and Death

In 2016, an estimated 107,000 deaths were caused by iron deficiency anemia and other nutritional deficiencies. Pregnant women with severe anemia are twice as likely to die during or shortly after pregnancy than non-anemic women. About 75% of children with brain and spine birth defects die before their fifth birthday; many of these birth defects could be prevented with folic acid (vitamin B9).

Nutritional deficiencies also impact survivors. For example, iron deficiency in childhood stunts cognitive development which hinders academic performance and future earnings potential. Spina bifida, a spinal birth defect, has varying degrees of severity, and often leads to life-long disability.

FFI's Role

Fortification is successful primarily because it does not require consumers to change their behaviors. Governments and industries, however, need to make systematic changes to maximize fortification’s health benefits. FFI helps country leaders promote, plan, implement, and monitor sustainable grain fortification programs.

Vitamins and Minerals Added to Grains

Each country sets standards to include the specific nutrients its population needs. The following vitamins and minerals are used in flour and rice fortification globally:

Iron, riboflavin, folic acid, zinc, vitamin A, and vitamin B12 help prevent nutritional anemia which improves productivity, maternal health, and cognitive development.
Folic acid (vitamin B9) reduces the risk of severe brain and spine birth defects. Fortifying with folic acid may also have a role in the child's mental health.
Niacin (vitamin B3) prevents the skin disease known as pellagra.
Riboflavin (vitamin B2) helps with metabolism of fats, carbohydrates, and proteins.
Thiamin (vitamin B1) prevents the nervous system disease called beriberi.
Vitamin B12 maintains functions of the brain and nervous system.
Vitamin D helps bodies absorb calcium which improves bone health.
Vitamin A helps individuals fight infections and helps prevent childhood blindness. It is often added to rice, cooking oils, margarine, or sugar instead of flour.
Calcium builds strong bones, helps transmit nerve messages and assists with muscle function and blood clotting. A few countries add calcium to flour, but it is more commonly added to other foods.
Selenium helps with reproduction and thyroid gland function.
Vitamin B6 is needed for enzyme reactions involved in metabolism.
Folic acid, vitamin B6 and vitamin B12 lower homocysteine levels.
Zinc helps children develop, strengthens immune systems, and lessens complications from diarrhea. Learn more about cereal grain fortification as a strategy to reduce zinc deficiency from our partners, IZiNCG.

While iodine is not a nutrient added to fortified cereal grains, it is commonly used to fortify salt. Insufficient iodine during pregnancy leads to lasting brain damage that can reduce a child’s IQ by 8-10 points. Even moderate deficiency at school age can reduce IQ by 3-5 points. Adding tiny amounts of iodine to salt is a cost-effective answer to the problem. Every dollar spent protecting children’s learning ability through salt iodization has a $30 impact. To learn more about iodine fortification, please visit the Iodine Global Network website.

Fortification as part of a country’s nutrition strategy is supported by global organizations such as UNICEF, the World Health Organization, the World Food Programme, the U.S. Centers for Disease Control and Prevention, the Global Alliance for Improved Nutrition, and Nutrition International. For the latest evidence and guidance on food fortification, see the World Health Organization’s fortification topic page.

MTHFR Genetic Variant

Everyone with the methylenetetrahydrofolate reductase (MTHFR) C677T genetic variant, even people who have a homozygous genotype (MTHFR 677 TT), can process all forms of folate, including folic acid. [1, 2] For women who are pregnant or who could become pregnant, blood folate concentration is important to help prevent a neural tube defect in a developing baby. [3] When compared to the C allele, the T allele on the MTHFR gene is associated with lower blood folate concentrations because it produces an enzyme with a reduced capacity to process folate. [3]

However, no matter which MTHFR genotype (CC, CT, or TT) a woman has, she can increase her blood folate concentration to a level to help prevent a neural tube defect by consuming 400 mcg of folic acid each day before and during early pregnancy, in addition to food with folate from a varied diet. [4]

[1] Crider KS, Zhu JH, Hao L, et al. MTHFR 677C->T genotype is associated with folate and homocysteine concentrations in a large, population-based, double-blind trial of folic acid supplementation. The American Journal of Clinical Nutrition. 2011;93(6):1365-1372.

[2] Tsang BL, Devine OJ, Cordero AM, et al. Assessing the association between the methylenetetrahydrofolate reductase (MTHFR) 677C>T polymorphism and blood folate concentrations: a systematic review and meta-analysis of trials and observational studies. The American Journal of Clinical Nutrition. 2015;101(6):1286-1294.

[3] Crider KS, Devine O, Hao L, et al. Population red blood cell folate concentrations for prevention of neural tube defects: Bayesian model. BMJ (Clinical Research Ed). 2014;349:g4554.

[4] Crider KS, Devine O, Qi YP, et al. Systematic Review and Bayesian Meta-analysis of the Dose-response Relationship between Folic Acid Intake and Changes in Blood Folate Concentrations. Nutrients. 2019;11(1).