Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

Food and health

Voluntary food fortification in the United States: potential for excessive intakes

Abstract

Background:

Historically, the voluntary addition of micronutrients to foods in the United States has been regarded as an important means to lessen problems of nutrient inadequacy. With expanding voluntary food fortification and widespread supplement use, it is important to understand how voluntary food fortification has an impact on the likelihood of excessive usual intakes. Our objective was to investigate whether individuals in the United States with greater frequency of exposure to micronutrients from voluntarily fortified foods (vFF) are more likely to have usual intakes approaching or exceeding the respective tolerable upper intake levels (UL).

Subjects/methods:

The National Cancer Institute method was applied to data from the 2007–2008 National Health and Nutrition Examination Survey (NHANES) to estimate the joint distribution of usual intake from both vFF and non-vFF sources for 12 nutrients and determine the probability of consuming these nutrients from vFF on a given day. For each nutrient, we estimated the distribution of usual intake from all food sources by quintile of probability of consuming vFF and compared the distributions with ULs.

Results:

An increased probability of consuming zinc, retinol, folic acid, selenium and copper from vFF was associated with a greater risk of intakes above the UL among children. Among adults, increased probability of consuming calcium and iron from vFF was associated with a greater risk of intakes above the UL among some age/sex groups.

Conclusion:

The high nutrient exposures associated with vFF consumption in some population subgroups suggest a need for more careful weighing of the risks and benefits of uncontrolled food fortification.

This is a preview of subscription content, access via your institution

Access options

Buy article

Get time limited or full article access on ReadCube.

$32.00

All prices are NET prices.

Figure 1
Figure 2
Figure 3

References

  1. Institute of Medicine (IOM). Dietary Reference Intakes: Guiding Principles for Nutrition Labeling and Fortification. Washington, D.C.: National Academies Press, 2003.

  2. United States Government. Code of Federal Regulations. Food and drugs: nutritional quality guidelines for foods. Fortification Policy: 21CFR104. Available at: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?fr=104.20. Accessed 12 October 2012.

  3. United States Government. Code of Federal Regulations. Food and drugs: food additives permitted for direct addition to food for human consumption. Special Dietary and Nutritional Additives: 21CFR172. Available at: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfCFR/CFRSearch.cfm?CFRPart=172&showFR=1&subpartNode=21:3.0.1.1.3.4. (accessed 02 October 2012).

  4. Fulgoni VL, Keast DR, Bailey RL, Foods DwyerJ . Fortificants, and supplements: where do Americans get their nutrients? J Nutr 2011; 141: 1847–1854.

    CAS  Article  Google Scholar 

  5. Berner LA, Clydesdale FM, Douglass JS . Fortification contributed greatly to vitamin and mineral intakes in the United States, 1989–1991. J Nutr 2001; 131: 2177.

    CAS  Article  Google Scholar 

  6. Kulik RF . Position of the American Dietetic Association: fortification and nutritional supplements. J Am Diet Assoc 2005; 105: 1300.

    Article  Google Scholar 

  7. Moshfegh A, Goldman J, Cleveland L . What We Eat in America, NHANES 2001–2002: usual nutrient intakes from food compared to dietary reference intakes. USDA, Agricultural Research Service 2005.

  8. Devaney B, Crepinsek M, Fortson K, Quay L . Review of Dietary Reference Intakes for Selected Nutrients: Challenges and Implications for Federal Food and Nutrition Policy. Mathematica Policy Research January 2007;; 28.

  9. Institute of Medicine (IOM) Food and Nutrition Board (FNB). (ed) Proposed Criteria for Selecting the WIC Food Packages: A Preliminary Report of the Committee to Review the WIC Food Packages. The National Acadamies Press: Washington, DC, 2004.

  10. Arsenault JE, Brown KH . Zinc intake of US preschool children exceeds new Dietary Reference Intakes. Am J Clin Nutr 2003; 78: 1011.

    CAS  Article  Google Scholar 

  11. Bailey RL, McDowell MA, Dodd KW, Gahche JJ, Dwyer JT, Picciano MF . Total folate and folic acid intakes from foods and dietary supplements of US children aged 1–13 y. Am J Clin Nutr 2010; 92: 353–358.

    CAS  Article  Google Scholar 

  12. Yeung LF, Cogswell ME, Carriquiry AL, Bailey LB, Pfeiffer CM, Berry RJ . Contributions of enriched cereal-grain products, ready-to-eat cereals, and supplements to folic acid and vitamin B-12 usual intake and folate and vitamin B-12 status in US children: National Health and Nutrition Examination Survey (NHANES), 2003–2006. Am J Clin Nutr 2011; 93: 172–185.

    CAS  Article  Google Scholar 

  13. Yang Q, Cogswell ME, Hamner HC, Carriquiry A, Bailey LB, Pfeiffer CM et al. Folic acid source, usual intake, and folate and vitamin B-12 status in US adults: National Health and Nutrition Examination Survey (NHANES) 2003-2006. Am J Clin Nutr 2010; 91: 64–72.

    CAS  Article  Google Scholar 

  14. Institute of Medicine (IOM). Strategies to reduce sodium intake in the United States. Washington, DC: The National Academies Press, 2010.

  15. Dodd KW, Guenther PM, Freedman LS, Subar AF, Kipnis V, Midthune D et al. Statistical methods for estimating usual intake of nutrients and foods: a review of the theory. J Am Diet Assoc 2006 10; 106: 1640–1650.

    Article  Google Scholar 

  16. Zhang S, Midthune D, Guenther PM, Krebs-Smith SM, Kipnis V, Dodd KW et al. A new multivariate measurement error model with zero-inflated dietary data, and its application to dietary assessment. Ann Appl Stat 2011; 5: 1456–1487.

    Article  Google Scholar 

  17. Tooze JA, Kipnis V, Buckman DW, Carroll RJ, Freedman LS, Guenther PM et al. A mixed-effects model approach for estimating the distribution of usual intake of nutrients: the NCI method. Stat Med 2010; 29: 2857–2868.

    Article  Google Scholar 

  18. Tooze JA, Midthune D, Dodd KW, Freedman LS, Krebs-Smith SM, Subar AF et al. A new statistical method for estimating the usual intake of episodically consumed foods with application to their distribution. J Am Diet Assoc 2006; 106: 1575–1587.

    Article  Google Scholar 

  19. Verkaik-Kloosterman J, Dodd KW, Dekkers AL, van 't Veer P, Ocké MC . A three-part, mixed-effects model to estimate the habitual total vitamin D intake distribution from food and dietary supplements in Dutch young children. J Nutr 2011; 141: 2055–2063.

    CAS  Article  Google Scholar 

  20. Taylor CL, Meyers LD . Perspectives and progress on upper levels of intake in the United States. J Nutr 2012; 142: 2207S–2211SS.

    CAS  Article  Google Scholar 

  21. Munro IC . Setting tolerable upper intake levels for nutrients. J Nutr 2006; 136: 490S–492S.

    CAS  Article  Google Scholar 

  22. Carriquiry AL, Camaño-Garcia G . Evaluation of dietary intake data using the tolerable upper intake levels. J Nutr 2006; 136: 507S–513S.

    CAS  Article  Google Scholar 

  23. Zlotkin S . A critical assessment of the upper intake levels for infants and children. J Nutr 2006; 136: 502S–506S.

    CAS  Article  Google Scholar 

  24. Hannon EM, Kiely M, Flynn A . The impact of voluntary fortification of foods on micronutrient intakes in Irish adults. Br J Nutr 2007; 97: 1177.

    CAS  Article  Google Scholar 

  25. Flynn A, Hirvonen T, Mensink GB, Ocke MC, Serra-Majem L, Stos K et al. Intake of selected nutrients from foods, from fortification and from supplements in various European countries. Food Nutr Res 2009; 53, DOI: 3402/fnr.v53i0.2038.

  26. Galvin MA, Kiely M, Flynn A . Impact of ready-to-eat breakfast cereal (RTEBC) consumption on adequacy of micronutrient intakes and compliance with dietary recommendations in Irish adults. Public Health Nutr 2003; 6: 351.

    CAS  Article  Google Scholar 

  27. Gibson SA . Micronutrient intakes, micronutrient status and lipid profiles among young people consuming different amounts of breakfast cereals: further analysis of data from the National Diet and Nutrition Survey of Young People aged 4 to 18 years. Public Health Nutr 2003; 6: 815.

    PubMed  Google Scholar 

  28. USDA Food and Nutrient Database for Dietary Studies, 4.1. Beltsville, MD: US Department of Agriculture, Agricultural Research Service, Food Surveys Research Group, 2010.

  29. Briefel RR, McDowell MA, Alaimo K, Caughman CR, Bischof AL, Carroll MD et al. Total energy intake of the US population: The third National Health and Nutrition Examination Survey, 1988–1991. Am J Clin Nutr 1995; 62 (5 Suppl), 1072S–1080S.

    CAS  Article  Google Scholar 

  30. Dwyer J, Picciano MF, Raiten DJ . Estimation of usual intakes: what we eat in America—NHANES. J Nutr 2003; 133: 609S–623S.

    Article  Google Scholar 

  31. Johnson MA, Smith MM, JT Edmonds . Copper, iron, zinc, and manganese in dietary supplements, infant formulas, and ready-to-eat breakfast cereals. Am J Clin Nutr 1998; 67: 1035S–1040S.

    CAS  Article  Google Scholar 

  32. Institute of Medicine (IOM). Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium and Carotenoids. National Academies Press: Washington, D.C, 2000.

  33. Shakur YA, Tarasuk V, Corey P, O'Connor DL . Vitamin and mineral supplement consumption in Canada: do supplement users differ from non-users in terms of nutrient inadequacy and risk of high intakes? J Nutr 2012; 142: 534–540.

    CAS  Article  Google Scholar 

Download references

Acknowledgements

JE Sacco is supported by a Canadian Institutes of Health Research Doctoral Research Award.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to V Tarasuk.

Ethics declarations

Competing interests

The authors declare no conflict of interest.

Additional information

Contributors: JS and VT designed the research; KD adapted the NCI method macros to perform the statistical analysis; JS conducted research and performed statistical analysis; KD and SK provided critical input on the analysis and interpretation; JS had primary responsibility for writing the paper. All authors read and approved the final manuscript.

Supplementary Information accompanies this paper on European Journal of Clinical Nutrition website

Supplementary information

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Sacco, J., Dodd, K., Kirkpatrick, S. et al. Voluntary food fortification in the United States: potential for excessive intakes. Eur J Clin Nutr 67, 592–597 (2013). https://doi.org/10.1038/ejcn.2013.51

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/ejcn.2013.51

Keywords

  • voluntary food fortification
  • NHANES
  • tolerable upper intake level

Search

Quick links