Abstarct: Reformulation, a change to a food or beverage’s processing or composition, can reduce potentially harmful ingredients such as salt, added sugar, and saturated and trans fats or increase potentially beneﬁcial ingredients or nutrients such as ﬁber, protein, and micronutrients. Poor nutrition and health outcomes of populations have stimulated programs and policies to reduce the intake of salt, added sugar, and unhealthy fats and increase healthy nutrients and ingredients to meet recommended targets of a healthy diet. Alongside promoting the consumption of whole, nutritious foods (e.g., fruits, vegetables, and whole grains), reformulation, including fortiﬁcation of processed foods, has been utilized by food industry manufacturers to contribute to improving diets and aligning with national dietary guidelines. This paper summarizes a literature review and twenty semi- structured interviews with experts on food product reformulation and fortiﬁcation to highlight the challenges, limitations, and opportunities for increasing their effectiveness. While studies have shown that reformulation could have beneﬁcial public health impacts, such as iodized salt, there are a dearth of rigorous evaluations, particularly for some types of reformulations. Importantly, some evidence suggests that ultra-processing has signiﬁcant adverse health effects independently of nutrient adequacy. To improve population health, reformu-lation should be complemented with a range of approaches, including food taxes and subsidies, public food procurement, restrictions on food advertising and marketing, front-of-pack labeling, and changes to food envi-ronments that improve availability, affordability, and demand for whole and minimally processed foods.
There is growing evidence on the detrimental effects of unhealthy diets on nutrition and health outcomes, including non-communicable diseases (NCDs) such as cardiovascular disease, diabetes, and some types of cancers (Afshin et al., 2019). According to the 2019 Global Burden of Disease Study, unhealthy diets are one of the leading risk factors of disease burden and global mortality resulting in 348 million and 447 million deaths in females and males, respectively (Murray et al., 2020). Unhealthy diets tend to be low in fruits, vegetables, whole grains, le-gumes, nuts, and seeds, with poor micronutrient, essential fatty acid, and ﬁber content, and high in foods laden with excessive sugar, salt, unhealthy fats, and other additives (Afshin et al., 2019; Imamura et al., 2015; Swinburn et al., 2019; Willett et al., 2019).
With poor diets on the rise and deteriorating nutrition among vulnerable segments of the global population, there has been signiﬁcant investments in programs and policies which aim to reduce micronutrient deﬁciencies, as well as the intake of salt, added sugar, and unhealthy fats (Herforth et al., 2019; Springmann et al., 2020). Several global and national commitments have been critical to improving diets and nutri-tion. For example, Sustainable Development Goals 2 and 3 provide broad targets to end all forms of malnutrition and reduce premature mortality from NCDs by 2030. Furthermore, the World Health Organi-zation (WHO) Global NCD Action Plan 2013–2020 aims to reduce pre-mature mortality from NCDs by 25 % by 2025 by providing key nutritional recommendations. Within this plan, the WHO recommends limiting salt intake to 5 grams per day, added sugar intake to 10 % of total energy (with even more signiﬁcant beneﬁts if lowered to 5 %), and total fat intake to 30 % of total energy. For fat intake, saturated fats should be limited to 10 % of total energy, and industrial trans-fatty acids (TFA) should be eliminated from the diet (WHO, 2014a). In alignment, national fortiﬁcation policies have been enacted worldwide to increase the micronutrient content of highly consumed staple foods. Ninety-one countries have mandatory wheat ﬂour fortiﬁcation, while 126 coun-tries have mandatory salt fortiﬁcation policies (Global Fortiﬁcation Data Exchange, 2023).
Reformulation is a critical strategy to meet these global goals, with an additional focus on ensuring that reformulated foods are affordable and accessible for all (WHO, 2014b; WHO, 2012). Reformulation is the process of altering the processing or composition of a food or beverage to improve the product’s nutrition proﬁle. This is achieved by reducing the content of harmful ingredients or increasing the amount of potentially beneﬁcial ingredients or nutrients in a food product (Scott et al., 2017). Examples of reformulation include reducing sodium, added sugars, saturated and TFA, and energy density; increasing, adding, or substituting healthier ingredients to replace unhealthy ones; or enhancing the healthfulness of products with dietary ﬁber or protein. Similarly, food fortiﬁcation adds essential vitamins and minerals to commonly consumed foods such as maize and wheat ﬂour, edible oil, rice, and salt. Fortiﬁcation may be undertaken to replace micronutrients lost during processing, such as milling of cereals, or to address micro-nutrient deﬁciencies in the population (Das et al., 2019). Because the global population ubiquitously consumes staple grains, oils, and salt, fortifying these foods with essential micronutrients allows for a broad reach without requiring major dietary behavior shifts.
Both reformulation and fortiﬁcation strategies often rely on nutrient proﬁling or ranking foods based on their nutrient composition (Drew-nowski, 2017; WHO, 2010). Industrial food and beverage manufacturers (ranging from small companies to multi-national food and drink pro-cessing conglomerate corporations) use this proﬁling to align their products with national food-based dietary guidelines, labeling man-dates, and other governmental policies to improve public health (Leh-mann et al., 2017). Products are also reformulated in response to government policy or public demands for reduced sugar, salt, or fat; the omission of certain additives; or to increase the healthfulness of their food products to improve health and nutrition outcomes.
The primary objective of this paper is to appraise the food product reformulation landscape and highlight the challenges and opportunities of altering foods and their contribution to healthy diets and improved nutrition. To a lesser extent, we also examine fortiﬁcation as another strategy to improve the nutrient content of foods. In this paper, we use existing literature and stakeholder interviews to highlight: (1) how and why reformulation and fortiﬁcation are implemented, including volun-tary and mandated strategies from industrial food and beverage manu-facturers and governments; (2) the technological and political challenges and opportunities of reformulation and fortiﬁcation; and (3) the public health impact of these approaches.