Today’s Dietitian
Vol. 28 No. 4 P. 6
Q: Many of my clients are concerned that fortified foods are inferior. How can I address their concern?
A: Consumers have been voicing concern over fortified foods, especially as the conversation around ultraprocessed foods heats up. People are seeking labels with fewer ingredients, which they define as “clean” and believe are healthier. Concerns about fortified foods are amplified by social media influencers and politicians, while food companies add to the confusion by producing and promoting these types of products as better-for-you. This leaves RDs in a frustrating position when trying to promote and defend healthful foods, especially when they can help fill nutrient gaps. As a dietetic professional, it is important to understand the history of fortification and why and how it came be. Below you’ll find an overview of the history of fortification, and the role fortified foods play in our food supply today.
The History and Impact of Fortification
In the late 1930s and early 1940s, enrichment and fortification programs began in the United States to help fight widespread nutrient deficiencies that were causing serious public health problems. For example, flour and bread were enriched with B vitamins, which helped reduce conditions such as pellagra and beriberi from niacin and thiamin deficiencies, respectively. “At the time, pellagra was in the top ten leading causes of death and considered the most severe nutrient deficiency in US history,” says Sylvia Klinger, DBA, MS, RDN, LDN, CPT, founder of Hispanic & Multicultural Nutrition Communications, and member of the Grain Foods Foundation Scientific Advisory Board. “The innovative enrichment effort was a very targeted response to real health crises of the time.” Today, Klinger says that we rarely hear of cases of severe nutrient deficiencies, as pellagra was virtually eliminated by 1960 thanks to enrichment innovations.
By 1991, food enrichment had been in place for several decades, but a solution was being sought for the increasing rate of neural tube defects (NTD) in newborns. In 1991, a large, international clinical trial conducted across 33 centers in seven countries followed 1,817 women who had previously experienced a pregnancy affected by a neural tube defect.1 These women were divided into four groups: (1) folic acid supplement; (2) 7-vitamin supplements (A, D, B1, B2, B6, C, and nicotinamide); (3) all supplements; and (4) no supplements. Supplements were given at time of conception. The results found that women who received 4,000 mcg of folic acid daily experienced a 72% reduction in NTD recurrence. Notably, the group receiving other vitamins showed no significant protective effect.
In 1998, the FDA implemented mandatory folic acid fortification of enriched cereal grain products. Postfortification analysis found a decline in NTD birth prevalence with an overall 28% reduction in prevalence (which would affect 1,326 births annually).2 “The greatest improvements were seen in populations with limited access to prenatal care,” says Klinger. This decline has remained relatively stable until today.
To help close the folic acid gap among several culturally diverse populations, in 2016 the FDA amended the food additive regulations to allow for the addition of folic acid to corn masa flour up to 0.7 mg per pound, however, it remains voluntary.3 In 2024, the California legislature passed a bill requiring the fortification of corn masa flour with folic acid starting January 1, 2026.4
Fortification Today
Today, misinformation and hot trends are being quickly transmitted via social media resulting in the reemergence of some nutritional deficiencies and casting doubt on the quality of fortified foods. For example, iodine deficiencies have been recently reported, specifically in women of childbearing age and those on strict diets.5 With the major sources of dietary iodine in the US being dairy products and iodized salt,5 the rise of salts that are not iodized and the elimination of dairy in some diets have been contributing factors.
In addition, with Americans eating five to six servings of refined grains daily, which represents approximately 84% of American grain intake, fortified grains are important.6 “While most Americans have more access to food than they did 100 years ago, nutrient gaps still exist,” Klinger says. “Many people fall short on nutrients like iron, folate, vitamin D, and fiber. Enrichment and fortification continue to serve as a safety net, especially for vulnerable populations and those who may not consistently eat a balanced diet.”
Further, the 2020-2025 Dietary Guidelines for Americans recommend that half of dietary grains be whole.7 This recommendation allows the nutrients in fortified grains to complement those found in whole grains. “Whole grains naturally provide fiber, minerals, and antioxidants, but they don’t always cover all of the nutrients that fortification provides,” says Klinger, who points out that enriched refined grains deliver folic acid, which is critical for women of childbearing age. As such, “Pairing enriched and fortified foods with whole grains gives people a ‘best of both worlds’ approach to meeting nutrient needs,” she explains.
In addition to inclusion of certain vitamins and minerals, today’s fortified foods may contain added omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) found in infant formula.8 Fortification of eggs, yogurt, and milk with EPA and DHA is also increasingly common.
Recommendation for Dietetic Practitioners
Consumers, especially younger generations, did not experience deficiency as was seen in the 1900s. When educating clients, dietitians should communicate that enrichment and fortification have always been about filling gaps in the diet. “Adding nutrients back into refined grains or cereals has prevented serious health problems on a population level,” Klinger says. So, when clients express concern that fortified food is inferior, explain that choosing less processed foods is a good habit, fortified foods can still play an important and evidence-based role in supporting health, and fortified foods are a choice that clients can feel good about.
— Toby Amidor, MS, RD, CDN, FAND, is founder of Toby Amidor Nutrition (tobyamidornutrition.com) and a Wall Street Journal bestselling author. She’s written 12 cookbooks, including her latest, Healthy Living High-Protein Cookbook (June 2026). She’s also an award-winning media dietitian, spokesperson, and nutrition expert for FoodNetwork.com and a contributor to U.S. News and World Report and other national outlets.
Send your questions to Ask the Expert at TDeditor@gvpub.com or send a tweet to @tobyamidor.
References
1. Prevention of neural tube defects: results of the Medical Research Council Vitamin Study. MRC Vitamin Study Research Group. Lancet. 1991;338(8760):131-137.
2. MMWR: Updated estimates of neural tube defects prevented by mandatory folic acid fortification—United States, 1995-2011. CDC website. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6401a2.htm. Published January 16, 2025.
3. Fortifying corn masa flour products with folic acid. FDA website. https://www.fda.gov/food/food-additives-petitions/fortifying-corn-masa-flour-products-folic-acid. Updated June 3, 2024. Accessed October 8, 2025.
4. AB 1830: Corn masa flour and wet corn masa products: folic acid fortification. CalMatters website. https://calmatters.digitaldemocracy.org/bills/ca_202320240ab1830. Published September 28, 2024. Accessed October 8, 2025.
5. Niwattisaiwong S, Burman KD, Li-Ng M. Iodine deficiency: clinical implications. Cleve Clin J Med. 2017;84(3):236-244.
6. Ahluwalia N, Herrick KA, Terry AL, Hughes JP. Contribution of whole grains to total grains intake among adults aged 20 and Over: United States, 2013-2016. NCHS Data Brief. 2019;(341):1-8.
7. The 2020-2025 Dietary Guidelines for Americans. USDA and HHS website. https://www.dietaryguidelines.gov/sites/default/files/2021-03/Dietary_Guidelines_for_Americans-2020-2025.pdf. Accessed October 8, 2025.
8. Ganesan B, Brothersen C, McMahon DJ. Fortification of foods with omega-3 polyunsaturated fatty acids. Crit Rev Food Sci Nutr. 2014;54(1):98-114.