Mass fortification of iron, iodine still not the standard

“​We estimate there are 197 countries in the world, and 167 have access to enough wheat, maize and rice that if they fortified any of these or a combination, depending on what foods are most consumed in the country, they would improve nutritional status,”​ Helena Pachón, PhD, MPH, senior nutrition scientist at the Flour Fortification Initiative, told NutraIngredients-USA. “Given that iron deficiency is clearly a problem in developed and developing countries and that other nutrients are clearly a problem in developing countries—most of these countries would have nutritional cause to consider fortification as a strategy to increase nutrient levels.”​ Still, only 78 countries require fortification of cereal grains.

Iron is a key component of myelin sheaths, which wrap around neurons in the brain. If a cognitive sheath is not fully formed, the neurons are not protected and can’t make connections they should be able to make. This is important during the fetal period and first few years of life, Pachón noted.

“Losses to cognitive development that are incurred when children don’t get enough iron are never regained. You can’t make up for it later,”​ added Sarah Zimmerman, communications coordinator of the Flour Fortification Initiative.

Elsewhere, studies have shown that iodine deficiency during pregnancy and infancy may also impair growth and neurodevelopment of infants and increase infant mortality; while deficiency during childhood reduces somatic growth and cognitive and motor function, according to research published in Endocrine Reviews​ by Michael B. Zimmermann, Human Nutrition Laboratory, Swiss Federal Institute of Technology Zurich, Zurich, Switzerland.

As iodine intakes in industrialized countries, including the United States and Australia, have fallen in recent years, concerns surrounding deficiency has grown. But assessing iodine status in pregnancy is difficult, and it is still unclear whether iodine intakes are sufficient among pregnant women, leading to calls for iodine supplementation during pregnancy in several industrialized countries, Dr. Zimmermann wrote.

Cognitive development has many influencers​

Several interrelated factors influence a child’s IQ aside from iodine and iron intake, which makes it difficult to secure reliable data, said Dr. Pachón.

“There are so many factors that influence mental development in children. It’s an area that’s hard to do research in,”​ she said. “Even if a child develops more mental capacity because he or she has enough iron in childhood, that doesn’t mean the child will have a good school or a good home environment, for example. You can’t have a control group.”​

In most countries, the best strategy to control iodine deficiency in populations (and one that is supported by the World Health Organization) is carefully monitored universal salt iodization. The Flour Fortification Initiative supports mass fortification of iron worldwide, too, though this isn’t necessarily the standard.

The different iterations of fortification​

The term “fortification” has various meanings. There isn’t a single most cost-effective solution, Dr. Pachón says, “because in all cases, you have to buy the vitamins and minerals. And the cost is usually borne by food industry and passed on to consumers.”​

Mass fortification refers to fortifying commonly consumed foods, such as cereal grains, salt or other condiments to provide consumers with additional amounts of essential vitamins and minerals without requiring people to change their behaviors. Point-of-use fortification, used most frequently in developing countries, adds single servings of micronutrients at meal time. Targeted fortification targets foods for specific groups that might not eat enough mass-fortified grain products to benefit from fortification, such as children younger than two years who can’t get sufficient micronutrients from breast milk anymore.

“​Breast milk plays an important role in meeting children’s nutritional needs, and for the first six months, they get all the nutrients they need from it. However, at about six months of age, babies need to start getting nutrient-rich food from sources such as fortified baby cereals,”​ said Dr. Pachón.

Mass fortification ‘not happening on as large a scale as we’d expect’​

Mass fortification is less effective as a strategy both if industries are not incentivized to fortify “either through carrot or stick,” or if the government does not regularly monitor the fortification program to see if it’s working as intended. Because resources for food control are typically limited, governments (justifiably) spend them investigating foods that can make us sick or kill us, not whether nutrients were added to food during fortification.   

Mass fortification is also less beneficial if the wrong concentration, i.e., too low, or the wrong compound is added to the fortified food. “This is particularly relevant for iron, where the cheapest compounds are less well absorbed by the body,”​ Dr. Pachón said.  

“While in the nutrition community we consider fortification, and especially mass fortification, to be a ‘standard’ or ‘classic’ intervention; in reality, it’s not happening on as a large a scale as we would expect, at least not for the cereal grains,” ​she added.