Fortification: What Have You Done For Me Lately?
Over the weekend, an opinion piece entitled “Vitamins hide the low quality of our food” was published in the New York Times. In the piece, author Catherine Price, makes a case against the practice of food fortification stating that “we use the presence of synthetic vitamins in so many of our foods as justification to continue to eat whatever we want, and seek to fill any remaining gaps via pills.” Is this really true?
Articles like this get under my skin because they spread emotional arguments that are often devoid of factual information and ultimately perpetuate false beliefs. Case in point, this article only references one scientific publication (on sulforaphane, which is not a vitamin – a curious choice for an article on vitamins), and only vaguely references the thoughts of anonymous “nutritionists”. Let’s go through some of the points discussed in this article and use actual data to back up our assertions, shall we?
“Even though an estimated two billion people around the world still don’t have access to adequate vitamins, most Americans have never experienced or seen the consequences of a serious vitamin deficiency.”
Fortunately, we live in a country where fortification practices have effectively eradicated the presence of certain vitamin deficiency diseases such as pellagra, but that’s not to say that we’re out of the woods just yet. As a for instance, women with an inadequate intake of folic acid during the time around conception have a significantly higher risk of having a child with a neural tube defect, the consequence of which can be as serious as death. Folic acid fortification became the law of the land beginning in 1998 (a time which I would argue that most Americans have “experienced or seen”), which has led to a 35% reduction of the incidence of neural tube defects.
Let’s assume collective nutritional amnesia hit the United States in 1999 – those deficiencies are all solved, right? Sadly no: the most current data from the CDC shows that 10.5% of Americans have a vitamin B6 deficiency, 8.1% of Americans have vitamin D deficiency, and 6% of Americans have vitamin C deficiency. These deficiencies can have consequences: according to the National Osteoporosis Foundation, 54 million Americans have or are at-risk of osteoporosis; a disease for which inadequate intakes of vitamin D and calcium are a major risk factor. Vitamin deficiencies are very much present in 2015 America, and chances are you see the effects daily whether you recognize it or not.
“Nutritionists are correct when they tell us that most of us don’t need to be taking multivitamins. But that’s only because multiple vitamins have already been added to our food.”
Ah, those anonymous nutritionists. This statement is confusing – are we saying that fortification is so effective that it has completely eliminated inadequate micronutrient intakes in the United States? And is the insinuation that this would somehow be a bad thing? The fact of the matter is that even if you account for the impact of food fortification, more than 90% of Americans don’t get enough of essential nutrients like vitamin D and vitamin E in their diets. Dietary supplement users have a significantly lower prevalence of inadequate intake of virtually all vitamins, so the data would actually be quite supportive of multivitamin use even in the presence of fortification. Fortification is an absolutely effective tool to prevent inadequate micronutrient intake (I’m looking at you, B-vitamins and iron), but it’s sadly not a magic bullet for every nutrient. Thankfully, we have tools like dietary supplements to help fill nutritional gaps. Nevertheless, micronutrient insufficiencies remain the norm and not the exception in the United States today.
Given the poor quality of the typical American diet, this fortification is far from superfluous. In fact, for products like milk and flour, where fortification and enrichment have occurred for so long that they’ve become invisible, it would be almost irresponsible not to add synthetic vitamins. If food companies didn’t do so voluntarily, the government might have to require it, to make sure that we didn’t accidentally eat ourselves into nutritional deficiencies.
Oh boy. Contrary to this assertion, the federal government does require nutrient fortification in certain instances. While some widespread fortification programs are voluntary (like iodine, believe it or not), many are in fact mandatory. The FDA has the ability to amend the statement of identity for certain foods to include the addition of fortificants, such as folic acid to grain products. The FDA established a formal fortification policy about 35 years ago, for the purpose of achieving “a desirable level of nutritional quality in the nation’s food supply” (or, preventing us from “accidentally eating ourselves into nutritional deficiencies”, as Ms. Price puts it). On the bright side, at least we can agree on something: it would absolutely be irresponsible – not to mention illegal! – for manufacturers to remove fortificants from our food supply because fortification is an invaluable public health tool.
“Luckily for manufacturers, the early days of the packaged foods industry coincided with the advent of synthetic vitamins, which made it possible to simply replace any vitamins that processing had destroyed. This fortuitous timing meant that manufacturers never had to publicly admit the nutritional inferiority of their products.”
Food processing is a necessary component of ensuring food safety. Processing techniques use things like heat to help transform a bunch of individual ingredients into foods that are both safe and delicious (at home, you may refer to this practice as “cooking”). Vitamins are not invincible, and manufacturing processes can destroy vitamins in the food. This is hardly a phenomenon that’s unique to the food industry, the same thing happens when you cook food in your kitchen at home. For instance, boiling vegetables practically eliminates the content of certain water-soluble vitamins like vitamin C and folate. The “fortuitous timing” of the discoveries of vitamins and their use in food manufacturing means nothing other than we could now solve a problem that had been plaguing humans for centuries. In fact, not utilizing proper cooking techniques for corn and maize is considered to be a causative factor in the widespread appearance of pellagra – one which was fortunately alleviated by niacin fortification.
Ultimately, I think the author’s heart is in the right place, and I believe that if she was a little more of a “nutrition agnostic” she’d be more willing to recognize the role that food fortification plays. We all want the same thing: to help everyone achieve a healthy diet. Fortification and dietary supplements are tools that are meant to help support a healthy diet. There’s no denying that fortification has been a remarkably effective public health tool, one which has had a tremendous impact on public health in the 20th century. Processed foods continue to be major contributors to nutrient intakes in the American diet, and they play an important role in ensuring food security and nutrition security in the modern age. The arguments against the use of processed foods and fortification (like the ones put forth by Ms. Price listed above) are more emotional than fact-based, and my hope is that we can move away from these emotional arguments and rely on data-driven arguments to help us move forward.
Bailey RL, Fulgoni VL, Keast DR, et al. Examination of vitamin intakes among US adults by dietary supplement use. J Acad Nutr Diet 2012; 112(5): 657-663.
Centers for Disease Control and Prevention. Second national report on biochemical indicators of diet and nutrition in the US population, 2012. Available at: http://www.cdc.gov/nutritionreport/pdf/exesummary_web_032612.pdf
Dwyer J, Wiemer KL, Dary O, et al. Fortification and health: challenges and opportunities. Adv Nutr 2015; 6(1): 124-131.
Fulvoni VL III, Keast DR, Bailey R, Dwyer J. Foods, fortificants, and supplements: Where do Americans get their nutrients? J Nutr 2011; 141: 1847-1854.
Park YK, Sempos CT, Barton CN, et al. Effectiveness of food fortification in the United States : the case of pellagra. Am J Public Health 2000; 90: 727-738.
Weaver CM, Dwyer J, Fulgoni VL III, et al. Processed foods: contributions to nutrition. Am J Clin Nutr 2014; 99: 1525-1542.
Williams J, Mai CT, Mulinare J, et al. Updated estimates of neural tube defects prevented by mandatory folic acid fortification – United States, 1995-2011. MMWR 2015; 64(01): 1-5.