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OCR for page 192
D
Voluntary Nutrient
Fortification
Fortification of foocis with one or more micronutrients is used as
a public health intervention intencleci to meet a clefineci population
health problem. Perhaps the most widely cited example of successful
fortification is the ioclination of salt for the control and prevention
of goiter and other iodine deficiency diseases (IDD). Salt ioclina-
tion is now practiced in at least 107 countries, with an estimated
overall coverage of 68 percent of households in those countries
(ACC/SCN, 2000~. Although IDD prevalence is falling rapidly, there
are 130 countries in which IDD is still consiclereci a public health
problem. In Canada, fortification of free-running table salt is man-
ciatory; in the United States, subject to state laws, it is voluntary. The
ioclination of salt continues to be actively promoted and has proven
to be an extremely effective intervention in the iocline-cleficient area
of the Great Lakes basin of both countries. In the United States, the
addition of niacin to cornmeal and flour for the control of pellagra,
at one time endemic in the southeast, and the fluoridation of water
to reduce dental caries have been clear success stories.
Efforts are now underway to achieve an equivalent success story
for vitamin A and iron in developing countries. Technology for
fortification is available but, because of the very limited use of pro-
cesseci foocis, there is very limited opportunity for fortification in
many of the countries most in neeci of fortified foocis (IOM, 1998b).
In North America, a very large proportion of the food supply is
processed, thus providing ample opportunity for fortification. The
technology of fortification and preparation of nutrient premixes
that are stable and do not cause taste, odor, or color changes are
192
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APPENDIX D
193
now available for a wicle variety of products. The food industry thus
can greatly increase the scope of fortification (more nutrients and
more foocis). However, with these advances in technology and greatly
increased scope of opportunity comes the risk of overfortification.
In the past, when a clear public health problem was iclentifieci
and only one or two foocis were being fortified, the planning and
monitoring of fortification was conceptually relatively easy. One
could proceed along the lines exemplified for the mock fortifica-
tion of fluici milk with vitamin A presented in Chapter 5. In the
planning stage the potential benefit of nutrient aciclition, as well as
the potential risk of excessive intake, could be preclicteci at a theo-
retical level. This could be clone not only for the target groups
where the public health problem was most severe, but also for other
population segments likely to consume the fortified food. This is
the type of preliminary planning that was clone in the United States
prior to increasing levels of fortification of breaci flour with folate in
the late 1990s. A clefineci public health problem existed, and only a
few foocis were targeted for the increased fortification.
Fortification planning has become complicated by three factors.
First, as noted previously, the opportunity for fortification has increased
tremendously and the number of foocis involved has increased in
the United States as manufacturers have implemented their own
fortification decisions. Therefore, inclivicluals may consume multiple
sources of the fortificant. Second, the food industry is technologi-
cally really to meet perceived neecis for nutrients, and with nutri-
ents for which the new recommencleci intakes may suggest increased
need (IOM, 1997, 1998a, 2000b, 2001, 2002a), industry is anxious
to respond. Third, there is an increased consumer awareness of
nutrient composition of incliviclual foocis through nutrition label-
ing and a general rise in interest in nutrition and its potential health
benefits. Over time, this has meant that labeled nutrient content
and associated claims or inferred benefits have become important mar-
ket influences. This places competitive pressure on the food inclus-
try to acici more and larger amounts of nutrients to foocis. Accorci-
ingly, the focus of nutrient fortification has shifted from carefully
orchestrated and closely monitored interventions to aciciress specified
public health problems to a much less controlled and broacler, non-
orchestrateci program of nutrient aciclitions to meet market clemancis
and competitive pressures. Where only a few fortified foocis were
marketed a few clecacles ago, there are now fortified and fabricated
foocis numbering in the thousands.
As an example, a recent study of U.S. food consumption (Berner
et al., 2001) evaluated the impact of 246 different fortified foocis on
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194
DIETARY REFERENCE INTAKES
nutrient intakes of populations. Children were found to be the most
likely to consume fortified foocis with 70 to 80 percent of children
age ci 1 to 10 years consuming foocis fortified with vitamins A and C,
thiamin, folate, or iron. In contrast, only 34 to 38 percent of adult
women consumed these foocis. A similar situation in Germany was
reported (Sichert-Helert et al., 1999) where children age ci 2 to 14
years consumed 479 different fortified food products.
In both the United States and Canada, food fortification has cre-
ateci difficult problems for government agencies involved in public
health monitoring. Canada is currently formulating a new policy on
fortification and designing new regulations uncler that policy
(Health Canada, 1999~. The fundamental difficulty is that fortifica-
tion regulations (minimum and maximum levels to be acicleci,
compulsory versus voluntary aciclition, etc.) relate to single foocis or
classes of commodities that are used interchangeably. For example,
stimulated by concerns over vitamin D deficiencies and possible
links between excessive vitamin D intake and cases of idiopathic
hypercalcemia, Canaclian regulations were moclifieci to allow the
aciclition of vitamin D to all types of milks, but to prohibit its acicli-
tion to most other types of foocis. The milk products were consici-
ereci to be interchangeable and mutually exclusive.
The regulatory framework was clevelopeci to aciciress the control
of rickets in Canada, while at the same time avoiding the problem
of infantile hypercalcemia, which haci been attributed to excessive
intakes of vitamin D (perhaps combined with high calcium intakes) .
This approach appeared to be effective in addressing the public
health problem, but clici not guarantee that every incliviclual would
ingest the recommencleci amount of vitamin D.
Many have urged that the regulations be easeci to allow aciclition
of vitamin D to a much wicler range of foocis, as is allowoci in the
United States. Such a relaxation of control would increase the like-
lihooci that those who cirank very little or no milk could get acle-
quate vitamin D from another food. However, there is also the con-
cern that excessive intakes may result if inclivicluals consume several
fortified foocis. Thus, a dilemma exists for regulatory agencies.
As stated earlier, with compulsory fortification of only a few foocis,
mock fortification studies (such as the vitamin A example in Chap-
ter 5) can be conclucteci to assess expected benefits and potential
risks associated with different levels of fortification. However, be-
cause the number of fortified foocis has increased, it is no longer
possible to run meaningful mock fortification scenarios.
Furthermore, it has not been possible for food composition data-
bases to stay current with the increasing numbers of foocis fortified
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APPENDIX D
195
with an array of different nutrients acicleci at different levels. Intake
ciata collected in national surveys would have to carry branci names
and perhaps manufacturing ciates in order to have accurate assess-
ments of intake for use in planning fortification programs. It is not
currently possible to use large national clietary studies to monitor
the public health impacts of fortification.
An aciclitional concern was highlighted by Whittaker and col-
leagues (2001) who examined iron and folate levels in 29 fortified
breakfast cereals. The analyze ci content of iron in these cereals
ranged from 80 to 190 percent of label values, with 21 of the 29
cereals containing 120 percent or more above label values. Analyzed
values for folate ranged from 98 to 320 percent of label values. In
aciclition, label values were baseci on a serving size of 30 g, but the
meclian measured serving size was 47 g for women and 61 g for
men. Consequently, intakes of iron and folate would be consicler-
ably higher than what would be estimated baseci on stanciarci por-
tion sizes and nutrition label information, with the prevalence of
intakes greater than the Tolerable Upper Intake Level being much
higher than preclicteci.
Food fortification thus has become a risk-risk situation that
requires balancing concerns of inacloquate intakes with concerns of
excessive intakes. One approach to solve this problem is to tightly
regulate aciclitional fortification efforts, but then the inclivicluals who
do not consume the existing fortified products would not have other
sources available to achieve adequate dietary intake. Another option
is to allow industry to respond to market clemanci and increase forti-
fication, but then the risk of excessive levels of intake among those
consuming multiple fortified products or high amounts of single
fortified foocis increases.
Nutritionists generally do not think in terms of acloquacy of incli-
vidual foods. Rather, limits of intake (inadequacy to excess) are
baseci on "habitual clietary intakes," or the self-selecteci mix of foocis
consumed over long periods by inclivicluals. Fortification regulations
have to relate to single foods or groups of foods. The increasing use
of over-the-counter pharmaceutical supplements and clietary sup-
plements, potentially by the same health-conscious people who scan
nutrition labels for foods with the highest available nutrient levels,
must also be factored into decisions on nutrient fortification policy.
Representative terms from entire chapter:
nutrient fortification
