The benefits, at a national level, of historical fortification efforts are generally not well documented; however, epidemiological evaluations of pilot-scale programs are considered to have played an important role in the widespread implementation of these programs. Iodization of salt was found to decrease the incidence of goiter by 74-90% in different counties in the State of Michigan in the US in the first 10 years of the program (1924-35). Salt iodization is credited with the elimination of endemic cretinism and endemic goiter in Switzerland. Since its inception in 1922, periodic evaluations of the program triggered increases in fortification of levels of iodine, most recently in 1998. In 2001, an evaluation of a national sample of Swiss school children and pregnant women showed adequate iodine status, underscoring the importance of iodized salt in that nation's food supply and the value for periodic monitoring in the success of a fortification program.
A successful intervention with vitamin A-fortified margarine initiated in Newfoundland in 1944-45 led to a marked improvement in vitamin A status, as indicated by serum retinol levels in a sample of the population. Similarly, observations on the curative effects of milk fat, but not of margarine, eventually led to the enrichment of margarine with vitamin A in Denmark.
An evaluation of the possible health impact of nia-cin fortification of cereal grains in the US showed that fortification played a significant role in the decline of pellagra-attributed mortality in the 1930s and 1940s and, finally, in the elimination of pellagra in the country. Fortification was particularly significant during a period when food availability and variety were considerably less than are evident today.
Effectiveness of iron fortification is less clear owing primarily to the complex etiology of anemia. Several cereal grain products and other foods, especially breakfast foods, are commonly fortified with iron in developed countries and iron fortification is generally assumed to be responsible, at least in part, for the marked reduction in the prevalence of iron deficiency anemia in these countries. However, many other factors, such as improved socioeconomic conditions, increased meat intake, and iron supplementation may have played important roles. Furthermore, the most common iron source used in cereal fortification in Western countries is reduced iron, which has been found to be poorly bioavail-able. Nevertheless, the effectiveness of iron fortification is apparent in some cases. For example, in Sweden, fortification of flour with iron was withdrawn in January, 1995, because the benefits of such fortification were considered uncertain. However, recent investigations suggest that, after accounting for possible confounding factors, iron intake decreased by 39% and iron deficiency anemia increased by 28% among adolescent girls in the 6 years following withdrawal of iron fortification. The effectiveness of iron fortification is also clear in the case of targeted fortification of infant foods. The use of iron-fortified infant formulas and cereals is credited with the virtual elimination of iron deficiency among American infants.
The effectiveness of food fortification as a public health strategy is evident in the case of recent folate fortification efforts. Since its inception in November, 1998, folic acid fortification (150 mgper 100 g of food) in Canada has produced measurable benefits. In Newfoundland, the average rates of neural tube defects, which remained unchanged between 1991 and 1997, fell by 78% with concurrent increases in blood folate levels of women after the implementation of folic acid fortification. This survey did not find evidence of improved folate status masking hematological manifestations of vitamin B12 deficiency, which was a concern carefully considered in setting the fortification levels of folic acid. Studies in other Canadian provinces also report significant reductions in neural tube defects: up to 32% in Quebec, 48% in Ontario, and 54% in Nova Scotia. Folate fortification is also reported to be associated with a 60% reduction in neuroblastoma, an embryonic tumor, among Canadian children.
In the US, enriched cereal grain products have been required to be fortified with 140 mg of folic acid per 100 g of food since January, 1998. Since then, folate levels of baked products, cereal grains, and pasta have doubled or tripled and breakfast cereals are one of the most highly fortified food sources of folate. Consequently, typical folic acid consumption in the country is estimated to have increased by more than 200 mgday-1 due to fortification, along with a substantial improvement in folate status of different population groups. According to the Centers for Disease Control and Prevention, the rates of neural tube defects fell by about 26% from 1995-96 to 1999-2000 in the US although there is debate that this figure may be an underestimate. Careful monitoring and surveillance of the long-term effects of these fortification programs is needed to ensure desired benefits without unintended consequences.
Several factors are considered essential for the success of fortification as a public health intervention. Key among them are:
• a documented need for food fortification, i.e., assessing the gap between current and desired intakes;
• choosing an appropriate food vehicle(s) that is consumed by most of the population in relatively constant amounts;
• setting a fortification level that is not only efficacious in the target population but also safe for the general population;
• resolving any concerns of adverse nutrient interactions;
• establishing clear fortification regulations and policies;
• a public education campaign to increase consumer awareness; and
• periodic assessments of the impact of the intervention to determine any necessary adjustments to the fortification policy to ensure that the desired benefits are achieved and that excessive intakes are minimized.
Relevant government bodies, food industry, professional health organizations, consumer associations, and trade organizations play important roles in formulating a coordinated and concerted effort in the successful implementation of the fortification program.
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