Should we be fortifying foods with nutrients?

Scientists say fortifying foods with nutrients could help save lives, while critics say it's mass medication and unethical. Meg Carter hears the arguments.

Ten eggs, some meat fat and a portion of oily fish sounds like a recipe for an upset stomach. This is, however, what you'd need to eat each day to get the current recommended daily intake of vitamin D solely by managing your diet. And it underlines why, as the implications of vitamin deficiency hit the headlines once more, so, too, are the potential benefits of fortifying food.

Kellogg's, for one, will be adding vitamin D to every one of its children's breakfast cereals from Coco Pops to Rice Krispies by the end of this year, the company announced recently – in direct response to the growing issue in the UK of rising incidence of illnesses relating to vitamin D deficiency, such as rickets.

"Vitamin D has been climbing the ladder of interest amongst health professionals because as a nation, our intake is declining due to decreased exposure to sunlight due to skin-cancer concerns and because the types of food in which vitamin D is found naturally are not as popular as they used to be – especially among children," the Kellogg's UK nutritional manager Jenny Walton says.

Just before Christmas, experts at the Nuffield Department of Clinical Neurosciences at Oxford University called for mandatory vitamin D food fortification in Scotland to help cut the large numbers of people there developing multiple sclerosis. Vitamin D, which occurs naturally in eggs and oily fish, is produced by the skin when exposed to sunlight. It has traditionally been associated with bone health but, increasingly, is believed to impact on a range of other conditions such as diabetes, heart disease, various cancers and MS.

One of the first documented examples of food fortification was in the Southern United States in the early 1900s, where the authorities ordered niacin, or vitamin B3, to be added to grits – the coarsely ground corn that was a staple part of the diet of the poor – to help combat the rise of pellagra, a disease caused by chronic lack of niacin. The initiative, done without labelling or fuss, was highly effective.

The British government called for vitamins A and D to be added to margarine after the First World War because of the unavailability of butter. Fortification of white flour with calcium, iron, thiamine and niacin started in the 1930s. Both foods are still fortified this way.

The ongoing debate about whether the mandatory fortification of flour with folic acid should be introduced in the UK – a measure medical experts in the US, where this has been done for the past 10 years, believe helps reduce neural tube defects, including spina bifida – demonstrates that slipping extra nutrients into food might sound like a good idea at a time of health cost-cutting, but the ins and outs of food fortification are not clear-cut.

"Food fortification is as much about ethics and society as science," says Ursula Arens, a spokeswoman for the British Dietetic Association, the professional association for registered dieticians. "While traditionally staple foods such as flour, cereals and spreads have been seen as good 'vehicles' for added nutrients as such a large proportion of the population regularly eat them, the question remains: is mass medication through the food we eat the way to go?" Should everyone's food be fortified just because a small proportion of the population ignore health advice? Might some people object that basic foods fortified with vitamins are less natural than those that aren't? Opposition to the flouridisation of water, she points out, was very strong.

A balance must be struck between a government or food company saying it knows best and the right of an individual to have the freedom to choose what to eat – one reason why white flour is fortified, but wholemeal isn't, and why low-fat spreads (which aren't officially deemed to be margarine as they have less than 80 per cent fat content) aren't fortified.

Besides, voluntary fortification (when an individual food company independently decides to fortify its products) is often as not for marketing rather than public-service reasons – the emergence in recent years of a host of vitamin-enriched sports and fizzy drinks being a case in point. "Food fortification is a potential PR story for a food brand even if that company doesn't plaster reference to the added mineral or vitamin all of its packaging," Charles Banks, co-founder of the global food trends agency The Food People, says. "It's the same reason we're seeing a growing number of manufactured food products enhanced with added grams of certain natural ingredients, such as fruit – so a product can be sold as 'providing one of your five a day'."

Ethics aside, Arens adds: "Fortification doesn't mean you don't need a healthy diet as well, because of the other benefits a healthy diet brings."

Despite all this, food companies and retailers are monitoring this debate closely. Fortification "is an area we are researching very seriously with our suppliers", Annie Denny, special diets and health manager at Sainsbury's, says. "We have fortified a small number of products – such as some of our own-brand breakfast cereals, dairy products and juice drinks.... We believe this is an important area to focus on."

Walton agrees. "An interesting question is whether we will need food fortification in the future as we eat more healthily. It will be needed more in coming years, however, not less. The reason's simple when you consider how much food we need to eat today. The fact is that we now need to eat less than we did 40 years ago because our lifestyles have become less active, and when you eat fewer calories you've less chance of meeting your RDAs."

The fewer calories we need to maintain our energy levels, the more important it is to consume nutrient-rich foods to maximise the value of the calories we eat. Given the reluctance of some sections of the population to follow health advice by eating better, food fortification looks like it is here to stay. Kellogg's certainly thinks so. Next on its hit list after vitamin D, Walton says, is riboflavin – sometimes called the forgotten B vitamin – the deficiency of which is particularly high among breakfast-skipping teens.

What's in your cornflakes?

Commercial foods, especially cereals, are often fortified with vitamins and minerals.

Vitamin D

Good for bone health and may help prevent diabetes, heart disease, cancer and MS. Many of us, particularly children, may be deficient in it. Kellogg's plans to add it to all its children's cereals.

Niacin

In the early 1900s in the American South, niacin, or vitamin B3, was added to grits, a staple food of poor people, to combat pellagra, a disease caused by a niacin deficiency. It's added to flour in Britain.

Folic acid

Believed to help prevent neural tube defects when given to pregnant women, some believe folic acid should be added to flour, as it is in the US.

Iron

In Britain, around one in 10 women of childbearing age and about 25 per cent of pregnant women are deficient in this essential mineral. Flour has been fortified with iron in Britain since the 1930s.

Riboflavin

The "forgotten B vitamin" plays an essential role in the body's metabolism. A deficiency is rare except in those people with very poor diets, but riboflavin could be next on Kellogg's breakfast cereal hit list.