Liberal fortification of foods: the risks. A study relating to Finland

Calcium-fortified foods in public health programs: considerations for implementation

Low calcium intake is common worldwide and can result in nutritional rickets in children and osteomalacia in adults. Calcium-fortified foods could improve calcium intake. However, there is limited calcium fortification experience, with technical and practical issues that may hamper its adoption. The objective of this landscape review is to summarize these issues to help policymakers guide the planning and design of calcium fortification as a public health strategy. One challenge is the low bioavailability of calcium salts (∼20-40%); thus, large amounts need to be added to food to have a meaningful impact. Solubility is important when fortifying liquids and acidic foods. Calcium salts could change the flavor, color, and appearance of the food and may account for 70-90% of the total fortification cost. Safety is key to avoid exceeding the recommended intake; so the amount of added calcium should be based on the target calcium intake and the gap between inadequate and adequate levels. Monitoring includes the quality of the fortified food and population calcium intake using dietary assessment methods. Calcium fortification should follow regulations, implemented in an intersectorial way, and be informed by the right to health and equity. This information may help guide and plan this public health strategy.

Successful nutrition policy: improvement of vitamin D intake and status in Finnish adults over the last decade

Background

Due to vitamin D intake below recommendation (10 µg/day) and low (<50 nmol/l) serum 25-hydroxycholecalciferol (25(OH)D) concentration in Finnish population, the fortification of liquid dairy products with 0.5 µg vitamin D/100 g and fat spreads with 10 µg/100 g started in Finland in December 2002. In 2010, the fortification recommendation was doubled. The aim of this study was to investigate whether the vitamin D intake and status have improved among Finnish adults as a consequence of these nutrition policy actions. A further aim was to study the impact of vitamin supplement use to the total vitamin D intake.

Methods

A cross-sectional survey was conducted every 5 years. The National FINDIET Survey was conducted in Finland as part of the National FINRISK health monitoring study. Dietary data were collected by using a computer-assisted 48-h dietary recall. In 2002, dietary data comprised 2007, in 2007, 1575 and 2012, 1295 working aged (25-64 years) Finns.

Results

The mean D-vitamin intake increased from 5 µg/day to 17 µg/day in men and from 3 µg/day to 18 µg/day in women from 2002 to 2012. The most important food sources of vitamin D were milk products, fat spreads and fish dishes. The share of milk products was 39% among younger men and 38% among younger women, and 29% among older men and 28% among older women. Fat spreads covered on average 28% of vitamin D intake, except for younger men for which it covered 23%. Fish dishes provided 28% of vitamin D intake for older men and women, and approximately 18% for younger ones. In January-April 2012, the average serum 25-hydroxycholecalciferol (25(OH)D) concentration for men was 63 nmol/l for men and for women 67 nmol/l for women.

Conclusions

The fortification of commonly used foods with vitamin D and vitamin D supplementation seems to be an efficient way to increase the vitamin D intake and the vitamin D status in the adult population.

Discretionary fortification--a public health perspective

'Discretionary fortification' refers to the addition of vitamins and minerals to foods at the discretion of manufacturers for marketing purposes, but not as part of a planned public health intervention. While the nutrients added may correspond to needs in the population, an examination of novel beverages sold in Toronto supermarkets revealed added nutrients for which there is little or no evidence of inadequacy in the population. This is consistent with the variable effects of manufacturer-driven fortification on nutrient adequacy observed in the US. Nutrient intakes in excess of Tolerable Upper Intake Levels are now observed in the context of supplement use and high levels of consumption of fortified foods. Expanding discretionary fortification can only increase nutrient exposures, but any health risks associated with chronically high nutrient loads from fortification and supplementation remain to be discovered. Regulatory bodies are focused on the establishment of safe levels of nutrient addition, but their estimation procedures are fraught with untested assumptions and data limitations. The task of determining the benefits of discretionary fortification is being left to consumers, but the nutrition information available to them is insufficient to allow for differentiation of potentially beneficial fortification from gratuitous nutrient additions.

Use of voluntarily fortified foods among adults in Finland

Objective

To investigate the purchase and use of fortified foods, and to explore and compare background characteristics, food consumption and nutrient intakes among users and non-users of voluntarily fortified foods in Finland.

Design

A study based on the National FINDIET Survey 2007 (48 h recall), which included also a barcode-based product diary developed to assess the type, amount and users of voluntarily fortified foods. Logistic regression analysis was employed to investigate associations between background characteristics and the use of fortified foods.

Setting

Randomly chosen subgroup of 918 adult participants in the National FINDIET 2007 Survey.

Subjects

Men and women aged 25–64 years from five regions.

Results

The product group of voluntarily fortified foods purchased in the highest volume was yoghurts (44 % of the weight of all fortified food), followed by fruit drinks (36 %). The only characteristics independently associated with the use of voluntarily fortified foods were age (older people used them less commonly) and the consumption of fruit and vegetables (participants with the highest consumption used them more commonly). Users of fortified foods had higher consumption of yoghurt, juice drinks and ready-to-eat breakfast cereals (women only) than non-users, and lower consumption of boiled potatoes (men only).

Conclusions

Use of voluntarily fortified foods is associated with high consumption of fruit and vegetables but not with other health-related behaviours. The use of voluntarily fortified foods does not seem to even out the differences in nutrient intake among Finnish adults.

The cumulative effect of small dietary changes may significantly improve nutritional intakes in free-living children and adults

BACKGROUND/OBJECTIVES

The ELPAS (Etude Longitudinale Prospective Alimentation et Santé) study was an 8-month randomized controlled dietary modification trial designed to test the hypothesis that family dietary coaching would improve nutritional intakes and weight control in 2026 free-living children and parents. It resulted in significant nutritional changes, with beneficial effects on body mass index in adults. In these ancillary analyses, we investigated dietary changes throughout the intervention.

SUBJECTS/METHODS

Before the study, modeling analyses were carried out on the French Association Sucre Produits Sucrés Consommation et Communication (ASPCC) food-consumption database to identify the most efficient dietary intervention strategy. During the study, all participants performed monthly three nonconsecutive 24-h dietary recalls: this allowed for measuring changes in the number of servings per day and serving size for each targeted food category throughout the intervention.

RESULTS

Modeling analyses showed that targeting only the 10 main foods contributing to fat and carbohydrate intakes did not allow for reaching the ELPAS nutritional goals. As a result, it was decided to target more foods and to propose several types of dietary advice (such as change in serving size, change in cooking method, food substitution). This strategy led to many appropriate dietary changes during the intervention, but only a few of them reached significance. The mean number of servings per day was indeed significantly modified for only 7% of the targeted food categories in children and 17% in parents. The mean serving size was modified for only 12% of targeted food categories in children and 9% in parents.

CONCLUSIONS

The cumulative effect of small dietary changes may induce significant nutritional improvements, with limited burden for populations.

Health Canada's proposed discretionary fortification policy is misaligned with the nutritional needs of Canadians

Health Canada has proposed new fortification policies that will allow manufacturers to add vitamins and minerals to a wide variety of foods at their discretion and increase nutrient additions to breakfast cereals. Our objective was to examine the potential impact of these policies on nutrient inadequacies and excesses in the Canadian population. Using dietary intake data from the Canadian Community Health Survey, Cycle 2.2 (2004), usual intake distributions from food were estimated for vitamins A and C, folate, niacin, calcium, and magnesium for all age/sex groups. The prevalence of individuals with inadequate nutrient intake and the proportion of individuals with intakes above the tolerable upper intake level (UL) were assessed where possible, assuming full implementation of the proposed policies. To approximate a "mature market" scenario, consumption patterns of fortified foods in the United States were estimated and applied to Canadian intake data. Full implementation resulted in marked reductions in inadequate intakes of vitamin A, vitamin C, magnesium, and folate, and improvements in calcium intakes for some age/sex groups. However, it caused intakes of folate, niacin, vitamin A, and calcium to rise above the UL, particularly among younger age groups. Although increased food fortification may reduce the apparent prevalence of inadequate intakes for some nutrients, there is no evidence of inadequacies for niacin or several other nutrients slated for addition. Our modeling suggests that Health Canada's proposed policies are misaligned with the nutritional needs of the population, because they are not rooted in an assessment of current nutrient intake patterns.

Analysis of the impact of fortified food consumption on overall dietary quality in Irish adults

The aim of the present study was to assess the impact of fortified food (FF) consumption on overall dietary quality in Irish adults. Data for this analysis was based on the North/South Ireland Food Consumption Survey w7/15/2008hich used a 7 d food diary to collect food and beverage intake data in a representative sample of 1379 Irish adults (662 men and 717 women) aged 18–64 years. Foods contained in the database that are fortified were identified from the presence of vitamins and/or minerals in the ingredient list on the label. The results showed that an increased level of FF consumption was associated with lower intakes (percentage food energy) of total fat and saturated fat (women only) and higher intakes of total carbohydrate, total sugars (but not added sugars) and starch. Increased consumption was associated with a more micronutrient-dense diet and a reduced prevalence of dietary inadequacies of Ca, Fe, riboflavin and folate, particularly in women. Higher FF consumption was associated with higher intakes of fruit, lower intakes of alcohol and a lower likelihood of smoking in men and women. Thus it appears that FF consumption is a marker of both better dietary quality and healthy lifestyle behaviours.

Framework for intake simulation of functional ingredients

Objective

To create a general framework for the simulation of intakes from mandatory or voluntary fortification, which will make outcomes of simulation studies more comparable and give insight on uncertainties.

Design

A general framework was developed based on methods used in already published case studies of mandatory fortification. The framework was extended to be suitable for the simulation of voluntary fortification. Case studies of folic acid fortification were used to illustrate the general framework.

Results

The developed framework consists of six steps. First, the definition of the fortification strategy (step 1), followed by the identification of potential carrier products (step 2), and the definition of fortification levels or ranges (step 3). Thereafter, virtual food/supplement composition data are created (step 4) and food/supplement consumption data are required (step 5). Finally, the intake of the functional ingredient from functional foods, other foods and dietary supplements is calculated during the simulation resulting in total habitual intake distributions (step 6).

Conclusions

Simulation of both mandatory and voluntary folic acid fortification in The Netherlands showed that the general framework is applicable. Also with incomplete data or data from different sources, the (habitual) intake distributions can be estimated using assumptions, statistical procedures or probabilistic modelling approaches. It is important that the simulation procedure is described well, so that an insight on uncertainties and knowledge gaps to be filled is given.

Efficacy and safety of food fortification with calcium among adults in Finland

OBJECTIVE

To examine the efficacy and safety of foods fortified with calcium in the adult population in Finland.

DESIGN

A simulation study based on the FINDIET 2002 Survey, which estimated habitual food consumption, dietary supplement use and nutrient intakes using 48-hour recall and two 3-day food records, and an Internet survey of the consumption of fortified foods and dietary supplements.

SETTING/PARTICIPANTS

Participants of FINDIET 2002 were 25-64 years old from five areas (n = 2007). Participants of the Internet-based survey (n = 1537) were over 15 years of age from all over the country.

RESULTS

If all potentially fortifiable foods were to be fortified with calcium, the proportion of participants with calcium intake below the recommended level (< 800 mg day(-1)) would decrease from 20.3% to 3.0% in men and from 27.8% to 5.6% in women compared with the situation where no foods were fortified. At the same time, the proportion of participants with calcium intake above the tolerable upper intake level (UL, > 2500 mg day(-1)) would increase from 0.6% to 12.7% in men and from 0.1% to 3.8% in women. However, in a probability-based model (11% of all fortifiable foods to be fortified with calcium) the proportion of participants with calcium intake below the recommended level would be 15.7% in men and 23.2% in women. The proportion with intake above the UL in this model would be 1.2% in men and 0.7% in women.

CONCLUSIONS

Food fortification would be a relatively effective and safe way to increase the calcium intake of the Finnish adult population.

Longitudinal Changes in Intake and Food Sources of Calcium from Childhood to Young Adulthood: The Bogalusa Heart Study

OBJECTIVE

To examine changes in calcium intake and food sources of calcium from childhood to young adulthood in a longitudinal sample.

METHODS

Information on food and nutrient intake was derived from a single 24-hour dietary recall collected on children who participated in a cross-sectional survey at age 10 and again in young adulthood. A cohort of 237 young adults who participated in the 1989-1991 young adult survey (ages 19 to 28 years) also participated in one of three cross-sectional surveys from 1973 to 1978 at 10 years of age. Repeated measures analysis of variance was applied to examine the longitudinal changes in intake of calcium and food sources from childhood to young adulthood.

RESULTS

Total calcium intake at age 10 was not significantly different than total calcium intake of those same individuals when they were young adults. Gender and ethnic differences were observed within the two age groups. In both childhood (age 10 years) and young adulthood, African-American females had significantly lower total calcium intake than Euro-American males. However, this ethnic difference in total calcium intake did not exist after adjusting for energy intake. Calcium intake per 1000 kcal was significantly lower in females than males at age 10, but not in young adulthood. A large percentage of 10-year-olds did not meet the RDA or AI for calcium intake (54% and 88%, respectively), and this was also shown when they were young adults (77% and 75%, respectively).

CONCLUSIONS

More effective nutrition educational efforts are needed to emphasize the importance of adequate calcium intake and the major food sources of calcium, beginning early in childhood and continuing into young adulthood.

Potential intake of phytosterols/-stanols: results of a simulation study

BACKGROUND

Different doses of phytosterols/-stanols up to a maximum of 4.0 g/day have been used in human safety studies, whereas only one small-scale study investigated some detailed clinical information about consumption levels exceeding 8.6 g/day.

OBJECTIVE

To determine which population groups are likely to be at risk of excessive intakes if liberal enrichment of foods with phytosterols/-stanols will be allowed.

DESIGN AND SUBJECTS

Cross-sectional study among a representative sample (n=23 106) of the Dutch population, aged 20-60 y (MORGEN-project, 1993-1997). Phytosterol/-stanol intake was assessed with virtual replacement of one to four ordinary foods in the diet with enriched products. Percentile values were used to describe the distribution in simulated intake for different groups in the population, varying in sociodemographic and health characteristics. Multiple linear regression was used to describe the contribution of the different population characteristics to the simulated phytosterol/-stanol intake.

RESULTS

If three commonly consumed products (margarine, cheese, yoghurt) were completely replaced, the median daily phytosterol/-stanol intake will be about 5.5 g in men and 4.6 g in women. In males, the intake above the 90th percentile will exceed 8.6 g/day. Women will approach this level. Especially, age, body mass index, socioeconomic status, subjective health, smoking behaviour, alcohol consumption, pregnancy (women) and high cholesterol level (men) contributed to the variance in the simulated intake (P<0.05), although the total explained variance was low (1-3%).

CONCLUSIONS

If liberal phytosterol/-stanol fortification is allowed, the daily intake might exceed the recommended intake level as well as our 'cutoff' level of 8.6 g/day. Postlaunch monitoring to identify consumers and real intake levels, refinement of scenario buiding, as well as human safety studies for levels above 8.6 g/day are necessary.

Calcium intake trends and health consequences from childhood through adulthood

Issues involving low calcium intake and dairy product consumption are currently the focus of much debate and discussion at both the scientific and lay community levels. In this review, we examine the following major areas of interest: (1). the role of calcium intake and dairy product consumption in chronic diseases, (2). nutritional qualities of milk and other dairy products, (3). trends in calcium intake and dairy product consumption, (4). current status of calcium intakes and dairy product consumption in children, (5). tracking of calcium intake and diary product consumption, (6). the impact of school meal participation on calcium intake and dairy product consumption, (7). concerns related to calcium-fortified foods and beverages and (8). factors influencing children's milk consumption. To date, the findings indicate that calcium intake and dairy product consumption have beneficial roles in a variety of chronic diseases; dairy products provide an abundant source of vitamins and minerals; calcium intakes of children have increased over time, yet intakes are not meeting the current adequate intake (AI) calcium recommendations; dairy consumption has decreased, and soft drink consumption and, possibly, consumption of calcium-fortified products have increased; consumption of dairy products have a positive nutritional impact on diets of children, particularly from school meals, and there are many factors which influence children's milk consumption, all of which need to be considered in our efforts to promote adequate calcium intakes by children. Based on this review, areas that need immediate attention and future research imperatives are summarized in an effort to further our understanding on what we already know and what we need to know to promote healthier eating habits early in life.

Risk analysis applied to food fortification

OBJECTIVE

To describe how a risk analysis can be applied to food fortification, with emphasis on voluntary fortification and intake levels that might exceed usual dietary levels.

DESIGN

Use of the risk analysis model as a frame to classify nutrients according to the risk of exceeding upper safe intake levels. Furthermore, to apply the model when discussing possible consequences of liberal fortification practices on eating behaviour and disease patterns.

SETTING

The discussion on food fortification presently going on internationally.

RESULTS

Micronutrients can be classified according to their safety margin, i.e. the size of the interval between the recommended intake and the upper safe level of intake. We suggest that nutrients with a small safety margin, i.e. for which the upper safe level is less than five times the recommended intake, be placed in a category A and should be handled with care (retinol, vitamin D, niacin, folate and all minerals). Category B comprises nutrients with an intermediate safety margin (vitamins E, B6, B12 and C), while nutrients that according to present knowledge are harmless even at 100 times the recommendation (vitamin K, thiamin, riboflavin, pantothenic acid and biotin) are categorised as C.

DISCUSSION

The risk analysis model is a useful tool when assessing the risk of both too low and excess intakes of single micronutrients, but can also be applied to analyse the consequences of fortification practices on eating behaviour and disease patterns. Liberal fortification regulations may, for example, distort the conception of what is healthy food, and drive consumption towards a more unhealthy diet, contributing to the plague of overweight and concomitant increased risk of degenerative diseases.

CONCLUSION

The impact of fortification practices on the total eating pattern of a population should become an integrated part of the discussions and regulations connected to the issue.