Vitamin Fortification of Food Supplies

Have you seen pellagra, rickets or beriberi recently?  Probably not, although rickets is occasionally seen still in the US.  In the US  and in many other countries, public health measures are taken to  fact add micronutrients to the food supply to prevent these specific illnesses.

As early as 1938 fortification of food in the US with niacin was begun voluntarily as an additive  to bread to prevent the then epidemic problems of pellagra from niacin deficiency.  Soon after thiamine was added to prevent beriberi.  Vitamin D is commonly added to milk and other dairy products  to prevent Rickets, and in some countries folic acid is added to flour to prevent neural tube defects in babies.

A more controversial additive to water is fluoride.  Most areas of the US have fluoridation of the water to prevent dental caries.  Despite strong evidence that fluoridation of the water dramatically reduced cavities in our children, and evidence that besides destroying our teeth dental caries leads to other medical problems including coronary disease, some communities have resisted adding fluoride to the water.   I live in a community where the water is not fluorinated in many areas, so I prescribe fluoride supplements to babies starting at age 6 months.

So what are these problems we are preventing, and do they still happen?

Pellagra: Pellagra is caused by a deficiency of Niacin,  vitamin B3.  It reached epidemic proportions in the southern US during the first part of the 20^th century.  This was felt to be the result poorer workers diet of primarily corn which after being degerminated by the Beall Degerminator, invented in 1905, lost most of its niacin content as it was milled into cornmeal.   In 1941 the Food and Nutrition Board recommended the fortification of bread and flour with niacin, thiamine and iron.  By 1945 pellagra was extinct in the Southern US.  Clinical pellagra is characterized by the 3 D’s of diarrhea, dermatitis and dementia.  Untreated severe pellagra can cause death within 4-5 years.  Atypical causes of pellagra today include tryptophan deficiency.  Tryptophan is converted into niacin, and carcinoid syndrome can indirectly lead to tryptophan deficiency and then to pellagra.

Beriberi: This is from thiamine (Vitamin B1) deficiency.  It was endemic in the Japanese navy where the diet was almost exclusively white rice in lower ranking sailors.  Beriberi clinically presents with neuropathy (dry beriberi), congestive heart failure (wet beriberi), and neurologic sensory impairment (Wernike’s encephalopathy).  Thiamine deficiency is nearly unheard of in developed countries because it is added to many foods.  We see it essentially only in very malnourished alcoholics.  For this reason every med student learns to give all alcoholics IV thiamine in the ER prior to giving IV glucose as a part of treatment.  This prevents the precipitation of Wernike’s encephalopathy in some cases.

Rickets: Rickets is caused by vitamin D deficiency in children.  In adults this is called osteomalacia.  Rickets is a very common problem worldwide, primarily in malnourished children.  In the US it is seen occasionally in exclusively breast fed babies who do not get sun exposure.  Milk and baby formula in the US contains vitamin D supplementation, and the AAP recommends that babies not getting 17 ounces daily of formula or vitamin D fortified milk receive vitamin D supplementation.  Clinically rickets presents with bone deformities like becoming bow-legged in toddlers and having frequent fractures.

Overall the US has been fairly cautious in the widespread use of vitamin and mineral additives to the food supply.  It certainly appears that the few cases where public policy has led to the addition of vitamin D, niacin, thiamine and fluoride have been very successful.