ORIGINAL ARTICLE

Discretionary addition of vitamins and minerals

to foods: implications for healthy eating
JE Sacco and V Tarasuk
Faculty of Medicine, Department of Nutritional Sciences, University of Toronto, Toronto, ON, Canada
Objectives: Health Canada proposes to allow manufacturers to add vitamins and minerals to a wide variety of foods at their
discretion, a practice that has long been permitted in the United States and Europe. With Health Canadas proposed exclusion of
staple and standardized foods from discretionary fortification, questions arise about the nutritional quality of the foods that
remain eligible for fortification. To better understand the implications of this policy for healthy eating, this study examined the
contribution of foods eligible to be fortified to the dietary quality of Canadians.
Methods: Using 24-h dietary recall data from the 2004 Canadian Community Health Survey, the relationship between intake of
fortifiable foods and indicators of dietary quality was assessed.
Results: The mean percentage contribution of fortifiable foods to usual energy intake ranged from 19% among men over the
age of 70 years to 36% for girls aged 1418 years. Fortifiable food (as a percentage of total energy) was inversely associated with
intake of vegetables and fruit, meat and alternatives, milk products, fiber, vitamins A, B6, B12 and D, magnesium, potassium and
zinc. Fortifiable food was positively associated with dietary energy density, total energy intake and grain products. Few
relationships were found for folate, vitamin C, iron, calcium, sodium and saturated fat.
Conclusions: Consumption of foods slated for discretionary fortification is associated with lower nutrient intakes and suboptimal
food intake patterns. Insofar as adding nutrients to these foods reinforces their consumption, discretionary fortification might
function to discourage healthier eating patterns.
European Journal of Clinical Nutrition (2011) 65, 313320; doi:10.1038/ejcn.2010.261; published online 1 December 2010
Keywords: food fortification; dietary quality; vitamins; minerals
Introduction
Discretionary fortification, the addition of vitamins and
minerals to foods at the discretion of manufacturers, has
long been permitted in the United States (Food and Drug
Administration, 1993) and in parts of Europe (Sichert-Hellert
et al., 2000; Hannon et al., 2007), and in 2007, harmonized
regulations came into effect in the European Union
(European Parliament, 2006). A review of the Codex
Alimentarius general principles for the addition of vitamins
and minerals to foods has also been initiated, in part to
discuss the introduction of international standards for the
practice of discretionary fortification (Codex Alimentarius
Commission, 2007). The population health implications of
this practice have been the subject of little research, but
studies have indicated that discretionarily fortified foods
contribute significantly to overall nutrient intake and
apparent nutrient adequacy (Subar and Bowering, 1988;
Sichert-Hellert et al., 2000, 2001; Berner et al., 2001; Wagner
et al., 2005; Hannon et al., 2007). The effect of discretionary
fortification on food selection and dietary patterns has not
been examined, but as concerns about the growing pre-
valence of obesity mount, manufacturers use of nutrient
additions to market foods of otherwise low nutritional value
is coming into question (Nestle and Ludwig, 2010).
Although widespread discretionary fortification is not
currently permitted in Canada, a policy was proposed by
(Health Canada, 2005) and stakeholder consultations seem
to be ongoing (Yan, 2010). In the interim, components of the
proposed discretionary fortification policy are being used to
evaluate products for approval as Natural Health Products,
resulting in a recent increase in the availability of foods with
added vitamins and minerals in Canada (Natural Health
Products Directorate, Health Canada, 2006; Natural Health
Products Directorate and Food Directorate, 2009).
Received 18 August 2010; revised 27 October 2010; accepted 28 October
2010; published online 1 December 2010
Correspondence: Dr V Tarasuk, Faculty of Medicine, Department of
Nutritional Sciences, University of Toronto, FitzGerald Building, Room 326,
150 College Street, Toronto, ON M5S 3E2, Canada.
E-mail: valerie.tarasuk@utoronto.ca
European Journal of Clinical Nutrition (2011) 65, 313320
& 2011 Macmillan Publishers Limited All rights reserved 0954-3007/11
www.nature.com/ejcn
Similar to the assessments of discretionary fortification
policies in other jurisdictions (Coppens et al., 2006), Health
Canada conducted preliminary risk assessment modeling in
developing their proposed policy (Health Canada, 2005). This
assessment focused exclusively on safety considerations asso-
ciated with the potential for excess nutrient exposures. The
resultant policy proposal restricts the selection and levels of
nutrients that can be added; permitted nutrients include
vitamins E, D, C, B6 and B12, b-carotene, thiamin, niacin,
riboflavin, biotin, pantothenate, folate, calcium, magnesium
and potassium. The policy proposal also excludes certain staple
and standardized foods (such as those with a standard of
identity in the FDR (Food and Drug Regulations)) from
fortification (Supplementary Table 1). These are widely con-
sumed foods that, if fortified voluntarily, could pose risks of
excessive nutrient intake. However, foods left after these
exclusions include many snack foods (popularly termed junk
foods), leading some to argue that discretionary fortification
will promote an obesogenic diet (Beauchesne and Kondro,
2009). Such concerns arise because of the presumed marketing
potential associated with the nutritional enhancement of foods
(Moorman, 1998). However, there has been little research into
the effects of discretionary fortification on dietary behaviors.
To gain an understanding of the potential population
health implications of introducing a discretionary fortifica-
tion policy that could function to promote the consumption
of particular foods, we undertook an examination of the
contribution of fortifiable foods to the dietary quality of
Canadian adults and children currently.
Materials and methods
Ethics approval for this study was obtained from the
University of Toronto Research Ethics Board.
Dietary intake data from the Canadian Community Health
Survey, Cycle 2.2 (CCHS 2.2) were used. The CCHS 2.2
collected dietary intake data from 35107 Canadians in 2004
(Health Canada, Office of Nutrition Policy and Promotion,
Health Products and Food Branch, 2006) using an inter-
viewer-administered, multiple pass, 24-h recall (Statistics
Canada, 2008). A second 24-h recall was collected from
approximately one-third of the sample. The CCHS 2.2
sampled individuals from each of the 10 provinces, exclud-
ing members of the Canadian Forces, individuals living on
First Nations Reserves, Crown Lands, in prisons or care
facilities or those living in some remote areas. The sample
used for this analysis (n34383) also excluded respondents
with zero energy intakes, pregnant and lactating women,
children o1 year of age and those who only consumed
breast milk. The nutrient composition of foods found in the
database is derived primarily from the Canadian Nutrient
File (supplemented 2001b version) (Statistics Canada, 2008).
For this analysis, foods explicitly excluded by Health
Canada (Supplementary Table 1) were considered ineligible
for discretionary fortification, as were foods with a standard
of identity in the FDR because a regulatory amendment to
the FDR would be required to permit fortification of these
foods. All remaining foods in the CCHS database were
considered to be eligible for fortification (Supplementary
Table 2). Eligible foods comprise 32% of food codes in the
database. Fortifiable foods were grouped into nine classes
based on categories used in the Canadian Nutrient File
(Supplementary Table 2). To determine the most commonly
consumed fortifiable foods, the mean proportion of energy
intakes obtained from each class of fortifiable foods was
estimated. Survey weights were applied to these analyses,
incorporating the bootstrapping method of variance estima-
tion, which takes into account unequal probability of
selection and the stratification and clustering in the CCHS
2.2 survey design (Statistics Canada, 2008).
To characterize the habitual levels of consumption of
fortifiable foods among Canadians, the proportion of
individuals usual energy intakes obtained from fortifiable
foods was assessed. As food intake varies dramatically from
one day to the next, we used Software for Intake Distribution
Estimation (SIDE) (SIDE-IML version 1.11, 2001, Iowa State
University, Ames, IA, USA) to estimate the usual proportion
of energy intake from fortifiable foods, applying survey
weights (Statistics Canada, 2008). SIDE uses both 24-h
dietary recalls to estimate and attenuate the effect of random
within-individual variation, and to estimate the usual
proportion of energy intakes from fortifiable foods.
Linear regressions were conducted to examine the associa-
tion between fortifiable food consumption and dietary
quality, using each indicator of dietary quality as the
dependent variable, and the proportion of energy from
fortifiable foods as a single predictor. Indicators of dietary
quality included total energy intake, servings from each of
the four food groups (as defined in Canadas Food Guide
(Health Canada, 2007a)), and intake of nutrients for which
there are concerns of inadequate, suboptimal or excessive
intake in Canada, based on the assessment of nutrient
adequacy in CCHS 2.2 (Health Canada 2007b; Health
Canada, 2008a). These nutrients are saturated fat, fiber,
sodium, magnesium, iron, zinc, potassium, vitamins A, B6,
D, C and B12, calcium and folate. Examination of residual
plots revealed non-normally distributed residuals for
some nutrients; therefore, vitamins A, B12, C and D, iron
and zinc were (natural) log transformed in the regression
models presented in this study, to better approximate
normality.
Dietary energy density was also included as an indicator of
dietary quality, as it has been implicated in the development
of obesity (Ledikwe et al., 2005). Energy density was calculated
for each respondent by dividing the total energy intake in
kilojoules by the total amount of food consumed in grams,
excluding non-nutritive beverages because they can dispropor-
tionately influence energy density values (Ledikwe et al., 2005).
All analyses were conducted using SAS (version 9.2 (2008),
SAS Institute, Cary, NC, USA). Analyses were conducted
separately for 14 age and sex groups. Significance was
Addition of vitamins and minerals to foods
JE Sacco and V Tarasuk
314
European Journal of Clinical Nutrition
determined using the Bonferroni adjustment for multiple
comparisons (Po0.0002).
Results
Almost every respondents 24-h dietary recall (95%) included
at least one fortifiable food. The mean usual percentage
contribution of fortifiable foods to usual energy intake
among Canadians appeared to be highest among younger
age groups, ranging from 19% among men over the age of 70
years to 36% for girls aged 1418 years (Table 1). Particularly
among younger age groups, fortifiable foods comprised
upwards of 50% of usual energy intake for many individuals
(Figure 1). The fortifiable foods that contributed the most
to energy intakes were baked goods and beverages, and this
was consistent across all age/sex groups (Table 2).
For most age and sex groups, there was a significant
inverse relationship between the percentage of energy from
fortifiable foods and the number of servings of fruit and
vegetables, milk products, as well as meat and alternatives
(Table 3). Applying the b-values in Table 3 to current intakes
to further illustrate the magnitude of the associations, we
found that the decrease in fruit and vegetable intake
estimated to result from a shift from the 25th to the 75th
percentile of fortifiable food intake ranges from 0.1 servings
for men aged 470 years of age to 0.6 servings for men aged
1930 years of age. Significant positive relationships were
found for grain products, dietary energy density and total
energy intake, among almost all age and sex groups (Table 3).
Significant inverse associations were found for intakes of
vitamins A, D, B6 and B12, magnesium, zinc, fiber and
potassium (Tables 4 and 5). Few significant associations were
found for folate, calcium, vitamin C, iron, saturated fat or
sodium (Tables 4 and 5).
Discussion
Canadians derive a substantial proportion of their energy
intakes from foods that are eligible to be fortified under
Health Canadas proposed discretionary fortification policy.
The higher their intakes of these foods, the lower their
intakes of fruit and vegetables, milk products, meat and
alternatives, as well as many vitamins and minerals of
concern. These results suggest that fortifiable foods exert a
Table 1 Proportion of usual energy intakes from fortifiable foods in the Canadian population by age and sex group
a
Age (years)/sex N Percentiles
Mean s.d. 5th 10th 25th 50th 75th 90th 95th
%/d
Males/females
13 2193 23 9 9 12 16 22 29 36 40
48 3343 33 7 21 23 27 32 38 42 45
Males
913 2149 35 8 21 24 29 34 40 46 49
1418 2397 35 10 19 22 28 34 42 49 53
1930 1897 28 9 15 17 22 28 34 39 43
3150 2748 25 13 6 9 15 23 33 42 48
5170 2725 20 9 8 10 14 19 26 32 36
X71 1601 19 8 8 10 14 19 24 29 33
Females
913 2043 35 8 22 25 29 35 41 46 50
1418 2346 36 8 23 26 30 36 41 46 49
1930 1914 31 8 18 20 25 30 36 42 45
3150 2851 26 9 13 16 20 26 32 38 42
5170 3407 22 9 9 11 15 21 27 34 38
X71 2769 21 7 10 12 16 21 26 31 34
a
Based on analysis of data adjusted for day-to-day variability in nutrient intakes using Software for Intake Distribution Estimation (SIDE).
0 10 20 30 40 50 60 70
Percentage of Usual Energy from Fortifiable Foods
P
r
o
b
a
b
i
l
i
t
y

D
e
n
s
i
t
y

6
5
4
3
2
1
0
Boys Girls
median (boys) = 34%
median (girls) = 36%
Figure 1 Distribution of usual energy intake from fortifiable foods
for boys and girls aged 1418 years.
Addition of vitamins and minerals to foods
JE Sacco and V Tarasuk
315
European Journal of Clinical Nutrition
negative influence on the nutritional quality of individuals
intakes overall.
Although intakes of most micronutrients are inversely
associated with fortifiable food intake, there were some
notable exceptions. The absence of significant associations
between fortifiable food intake and both vitamin C and
folate for many age/sex groups may reflect the impact of
existing fortification programs. In Canada, fortification of
white flour and pasta with folic acid is mandatory,
contributing large amounts of folic acid to both fortifiable
and non-fortifiable foods (Health Canada, 2008b). Similarly,
the absence of significant findings for vitamin C may reflect
widespread consumption of vitamin C-fortified fruit-flavored
drinks, which are permitted under existing fortification
Table 2 Proportion of energy intakes from fortifiable foods by food category and DRI group
a,b
Age (years)/sex N All foods Dairy
products
Soups, sauces
and gravies
Fruit and
vegetable products
Beverages Nut, seed and
legume products
Baked
goods
Sweets Mixed
dishes
Snacks
Mean
(s.e.) %
Mean
(s.e.) %
Mean
(s.e.) %
Mean
(s.e.) %
Mean
(s.e.) %
Mean
(s.e.) %
Mean
(s.e.) %
Mean
(s.e.) %
Mean
(s.e.) %
Mean
(s.e.) %
Males/females
13 2193 23 (1) 2 (0) 1 (0) 2 (0) 3 (0) 1 (0) 7 (0) 3 (0) 2 (0) 2 (0)
48 3343 32 (0) 2 (0) 1 (0) 2 (0) 6 (0) 1 (0) 10 (0) 3 (0) 4 (0) 4 (0)
Males
913 2149 34 (1) 1 (0) 2 (0) 2 (0) 7 (0) 1 (0) 9 (0) 4 (0) 4 (0) 4 (0)
1418 2397 35 (1) 1 (0) 2 (0) 2 (0) 9 (0) 1 (0) 7 (0) 3 (0) 5 (0) 5 (0)
1930 1897 29 (1) 1 (0) 2 (0) 2 (0) 7 (0) 1 (0) 6 (0) 2 (0) 4 (0) 3 (0)
3150 2748 23 (1) 1 (0) 3 (0) 2 (0) 5 (0) 1 (0) 6 (0) 1 (0) 3 (0) 2 (0)
5170 2725 20 (0) 1 (0) 2 (0) 1 (0) 3 (0) 1 (0) 7 (0) 1 (0) 2 (0) 2 (0)
X71 1601 19 (1) 1 (0) 3 (0) 1 (0) 2 (0) 1 (0) 9 (1) 1 (0) 1 (0) 0 (0)
Females
913 2043 35 (1) 1 (0) 2 (0) 2 (0) 7 (0) 1 (0) 9 (0) 3 (0) 4 (0) 5 (0)
1418 2346 35 (1) 1 (0) 3 (0) 3 (0) 8 (0) 1 (0) 8 (0) 4 (0) 4 (0) 4 (0)
1930 1914 30 (1) 1 (0) 2 (0) 2 (0) 7 (0) 1 (0) 6 (0) 2 (0) 4 (0) 4 (0)
3150 2851 25 (1) 1 (0) 2 (0) 2 (0) 4 (0) 1 (0) 7 (0) 2 (0) 3 (0) 3 (0)
5170 3407 22 (1) 2 (0) 2 (0) 1 (0) 3 (0) 1 (0) 8 (0) 2 (0) 2 (0) 1 (0)
X71 2769 21 (0) 1 (0) 2 (0) 1 (0) 2 (0) 1 (0) 10 (0) 2 (0) 1 (0) 1 (0)
a
See Supplementary Table 2 for details on the specific foods included within each category.
b
Estimates incorporate survey weights and have been bootstrapped, taking into account the complex survey design.
Table 3 Regression coefficients for association between number of servings of each food group and percentage of energy from fortified foods
Age (years)/sex N Grain products Fruits and vegetables Milk products Meat and alternatives Energy density (kJ/g) Energy (kJ)
b (s.e.)
Males/females
13 2193 0.03 (0.00)* 0.02 (0.00)* 0.02 (0.00)* 0.01 (0.00)* 0.03 (0.00)* 5.43 (0.71)*
48 3343 0.01 (0.00)* 0.04 (0.00)* 0.01 (0.00)* 0.03 (0.00)* 0.04 (0.00)* 3.37 (0.63)*
Males
913 2149 0.01 (0.00) 0.03 (0.00)* 0.02 (0.00)* 0.04 (0.00)* 0.04 (0.00)* 4.62 (1.08)*
1418 2397 0.00 (0.01) 0.04 (0.00)* 0.02 (0.00)* 0.05 (0.00)* 0.05 (0.00)* 1.76 (1.33)
1930 1897 0.01 (0.01) 0.05 (0.00)* 0.01 (0.00) 0.06 (0.00)* 0.05 (0.00)* 0.01 (1.45)
3150 2748 0.03 (0.00)* 0.03 (0.00)* 0.00 (0.00) 0.05 (0.00)* 0.04 (0.00)* 5.35 (1.15)*
5170 2725 0.03 (0.00)* 0.02 (0.00)* 0.00 (0.00) 0.04 (0.00)* 0.03 (0.00)* 6.06 (1.08)*
X71 1601 0.04 (0.01)* 0.01 (0.01) 0.00 (0.00) 0.04 (0.01)* 0.02 (0.00)* 6.03 (1.23)*
Females
913 2043 0.02 (0.00)* 0.04 (0.00)* 0.01 (0.00)* 0.03 (0.00)* 0.05 (0.00)* 4.57 (0.88)*
1418 2346 0.01 (0.00) 0.04 (0.00)* 0.01 (0.00)* 0.03 (0.00)* 0.05 (0.00)* 3.11 (0.88)
1930 1914 0.01 (0.00) 0.04 (0.00)* 0.01 (0.00)* 0.03 (0.00)* 0.04 (0.00)* 2.19 (0.92)
3150 2851 0.01 (0.00)* 0.03 (0.00)* 0.00 (0.00) 0.03 (0.00)* 0.04 (0.00)* 3.54 (0.80)*
5170 3407 0.02 (0.00)* 0.02 (0.00)* 0.00 (0.00) 0.03 (0.00)* 0.03 (0.00)* 5.46 (0.68)*
X71 2769 0.03 (0.00)* 0.02 (0.00)* 0.00 (0.00) 0.02 (0.00)* 0.03 (0.00)* 5.25 (0.69)*
*Significant at Po0.0002.
Addition of vitamins and minerals to foods
JE Sacco and V Tarasuk
316
European Journal of Clinical Nutrition
regulations (Health Canada, 2008b). With the introduction
of discretionary fortification, the observed inverse associa-
tions between fortifiable foods and micronutrient intakes
can be expected to diminish for those nutrients slated for
addition under the proposed policy.
Two markers of poor dietary quality are saturated fat and
sodium. We found few significant associations between
fortifiable food intake and sodium, reflecting the ubiquity
of sodium in Canadians diets (Garriguet, 2007a). We also
found few significant associations for saturated fat. This
probably reflects the fact that, although some dietary
saturated fat is derived from the fortifiable foods, two major
sources of this nutrient, meat and dairy products, have been
excluded from fortification.
Table 4 Regression coefficients for association between nutrient intakes and percentage of energy from fortified foods
Age (years)/sex N Calcium (mg) Magnesium (mg) Potassium (mg) Iron (mg)
a
Zinc (mg)
a
Sodium (mg) Saturated fat (g) Fiber (g)
b (s.e.)
Males/females
13 2193 6.17 (0.71)
a
0.42 (0.12) 7.66 (1.29)* 0.002 (0.00) 0.003 (0.00)* 7.13 (1.44)* 0.02 (0.02) 0.02 (0.01)
48 3343 3.67 (0.51)* 0.83 (0.10)* 10.86 (1.01)* 0.001 (0.00) 0.005 (0.00)* 1.23 (1.25) 0.05 (0.01)* 0.02 (0.01)*
Males
913 2149 4.17 (0.79)* 1.03 (0.16)* 12.52 (1.62)* 0.002 (0.00) 0.005 (0.00)* 0.62 (2.08) 0.02 (0.02) 0.02 (0.01)
1418 2397 4.90 (0.89)* 1.77 (0.19)* 19.11 (1.88)* 0.004 (0.00)* 0.007 (0.00)* 5.82 (2.37) 0.06 (0.02) 0.06 (0.01)*
1930 1897 2.88 (0.91) 1.96 (0.23)* 21.02 (2.12)* 0.004 (0.00)* 0.008 (0.00)* 5.37 (2.62) 0.07 (0.02) 0.06 (0.01)*
3150 2748 0.02 (0.69) 1.04 (0.19)* 9.98 (1.79)* 0.001 (0.00) 0.005 (0.00)* 4.90 (2.15) 0.05 (0.02) 0.03 (0.01)
5170 2725 0.26 (0.63) 0.73 (0.19)* 8.01 (1.74)* 0.000 (0.00) 0.003 (0.00)* 8.53 (2.17)* 0.06 (0.02) 0.01 (0.01)
X71 1601 0.15 (0.81) 0.46 (0.25) 6.24 (2.29) 0.002 (0.00) 0.003 (0.00) 7.40 (3.12) 0.05 (0.02) 0.03 (0.02)
Females
913 2043 3.16 (0.67)* 0.99 (0.13)* 11.91 (1.36)* 0.000 (0.00) 0.004 (0.00)* 3.20 (1.71) 0.01 (0.02) 0.03 (0.01)*
1418 2346 3.85 (0.61)* 1.12 (0.13)* 12.72 (1.31)* 0.002 (0.00) 0.006 (0.00)* 0.76 (1.59) 0.02 (0.02) 0.03 (0.01)*
1930 1914 2.13 (0.65) 1.13 (0.15)* 10.88 (1.44)* 0.002 (0.00)* 0.005 (0.00)* 2.80 (1.70) 0.00 (0.02) 0.04 (0.01)*
3150 2851 0.68 (0.54) 1.09 (0.15)* 11.58 (1.31)* 0.001 (0.00) 0.004 (0.00)* 3.08 (1.59) 0.03 (0.01) 0.04 (0.01)*
5170 3407 0.08 (0.48) 0.60 (0.14)* 6.32 (1.26)* 0.000 (0.00) 0.003 (0.00)* 5.52 (1.39)* 0.05 (0.01)* 0.03 (0.01)
X71 2769 0.71 (0.52) 0.48 (0.15) 6.72 (1.32)* 0.001 (0.00) 0.003 (0.00)* 7.87 (1.41)* 0.02 (0.01) 0.01 (0.01)
*Significant at Po0.0002.
a
Iron and zinc have been log transformed.
Table 5 Regression coefficients for association between nutrient intakes and percentage of energy from fortified foods
Age (years)/sex N Folate (mg DFE) Vitamin A (mg RAE)
a
Vitamin C (mg)
a
Vitamin B6 (mg) Vitamin B12 (mcg)
a
Vitamin D (mcg)
a
b (s.e.)
Males/females
13 2193 1.37 (0.23)* 0.00 (0.00) 0.000 (0.00) 0.00 (0.00)* 0.01 (0.00)* 0.009 (0.00)*
48 3343 0.19 (0.19) 0.01 (0.00)* 0.004 (0.00)* 0.01 (0.00)* 0.01 (0.00)* 0.010 (0.00)*
Males
913 2149 0.04 (0.29) 0.01 (0.00)* 0.001 (0.00) 0.01 (0.00)* 0.01 (0.00)* 0.012 (0.00)*
1418 2397 0.50 (0.34) 0.01 (0.00)* 0.006 (0.00)* 0.02 (0.00)* 0.01 (0.00)* 0.015 (0.00)*
1930 1897 0.98 (0.40) 0.01 (0.00)* 0.007 (0.00)* 0.02 (0.00)* 0.01 (0.00)* 0.015 (0.00)*
3150 2748 0.37 (0.31) 0.01 (0.00)* 0.001 (0.00) 0.02 (0.00)* 0.01 (0.00)* 0.008 (0.00)*
5170 2725 0.90 (0.30) 0.00 (0.00) 0.000 (0.00) 0.01 (0.00)* 0.01 (0.00)* 0.007 (0.00)*
X71 1601 1.09 (0.36) 0.00 (0.00) 0.001 (0.00) 0.01 (0.00)* 0.01 (0.00)* 0.003 (0.00)
Females
913 2043 0.20 (0.25) 0.01 (0.00)* 0.003 (0.00) 0.01 (0.00)* 0.01 (0.00)* 0.010 (0.00)*
1418 2346 0.55 (0.24) 0.01 (0.00)* 0.002 (0.00) 0.01 (0.00)* 0.01 (0.00)* 0.012 (0.00)*
1930 1914 0.15 (0.26) 0.01 (0.00)* 0.007 (0.00)* 0.01 (0.00)* 0.01 (0.00)* 0.012 (0.00)*
3150 2851 0.02 (0.22) 0.01 (0.00)* 0.006 (0.00)* 0.01 (0.00)* 0.01 (0.00)* 0.008 (0.00)*
5170 3407 0.34 (0.21) 0.01 (0.00)* 0.003 (0.00) 0.01 (0.00)* 0.01 (0.00)* 0.005 (0.00)*
X71 2769 0.56 (0.22) 0.00 (0.00) 0.003 (0.00) 0.01 (0.00)* 0.01 (0.00)* 0.004 (0.00)*
Abbreviations: DFE, dietary folate equivalent; RAE, retinol activity equivalent.
*Significant at Po0.0002.
a
Vitamins A, D, C and B12 have been log transformed.
Addition of vitamins and minerals to foods
JE Sacco and V Tarasuk
317
European Journal of Clinical Nutrition
A more sensitive indicator of the adverse effect of
fortifiable foods on dietary quality is energy density.
Energy-dense diets have been found to reflect diets low in
fruit and vegetables, and high in saturated fat, trans fat and
refined carbohydrates (Kant and Graubard, 2005; Ledikwe
et al., 2006; Bes-Rastrollo et al., 2008; Savage et al., 2008).
Dietary energy density has also been associated with higher
energy intake, weight gain and obesity in a number of cross-
sectional and prospective studies (Kant and Graubard, 2005;
Ledikwe et al., 2006; Mendoza et al., 2007; Bes-Rastrollo et al.,
2008; Savage et al., 2008). Although 24-h recall data limit
our ability to draw inferences regarding individuals
habitual dietary patterns, those who consumed diets high
in fortifiable foods had a higher dietary energy density
(and higher total energy intake), lending support to concerns
that promoting the consumption of fortifiable foods may
contribute to obesity (Beauchesne and Kondro, 2009).
A limitation of this work is our inability to anticipate
which foods are likely to be fortified, and which consu-
mers will select these foods after implementation of discre-
tionary fortification. We therefore examined fortifiable food
consumption (as opposed to fortified food consumption).
The relationships we observed between fortifiable food
intake and dietary quality may be more or less pronounced
when discretionary fortification is implemented, depen-
ding on consumer and manufacturer responses to discre-
tionary fortification, and whether the nutrient is permitted
for addition.
Examinations of the contribution of fortified foods to
overall dietary quality in jurisdictions where discretionary
fortification is currently practiced have largely focused on
breakfast cereals. These studies suggest that breakfast cereal
consumption is associated with better dietary quality
(Nicklas et al., 1995; Barton et al., 2005; Song et al., 2006;
Joyce et al., 2009), particularly as it relates to increased milk
consumption (Nicklas et al., 1995; Barton et al., 2005; Song
et al., 2006), but leave open the question of the contribution
of other fortified foods to overall dietary quality. Breakfast
cereals were not considered in our analysis because they are
subject to specific fortification regulations in Canada and do
not fall under the proposed discretionary fortification policy
(Health Canada, 2005; Department of Justice Canada, 2010).
Although we are unable to determine whether fortifiable
foods are displacing more healthful foods from the diets of
Canadians, the observed inverse association between the
consumption of fortifiable foods and milk products among
children and adolescents raises the possibility that fortifiable
beverages are displacing fluid milk. Further analyses (not
shown) confirmed that the intake of fortifiable beverages was
inversely associated with milk consumption among 913
year-old girls, but this association did not achieve statistical
significance for boys or for older youth. Our findings are
nonetheless concerning, insofar as discretionary fortification
reinforces this beverage selection.
Our earlier work modeling the impact of various imple-
mentation scenarios on the prevalence of nutrient inade-
quacies and excessive intakes in the Canadian population
suggests that, if fully implemented, Health Canadas pro-
posed discretionary fortification policy may not only reduce
existing prevalences of nutrient inadequacy in Canada but
it also has the potential to increase the risk of excessive
nutrient intakes (Sacco and Tarasuk, 2009). This was parti-
cularly true for children and adolescents, who tended to
experience larger shifts in their distribution of usual nutrient
intakes. This finding can be explained by our current
analysis, which indicates that younger individuals typically
derive a greater proportion of their energy intakes from
fortifiable foods.
Many of the foods that are identified as foods to limit in
Canadas Food Guide are eligible to be fortified. For example,
Canadas Food Guide advises Canadians to limit their intake
of foods and beverages high in calories, fat, sugar or sodium,
and provides a list of examples of such foods (Health
Canada, 2007a). This list includes cakes and pastries, cookies,
granola bars, chocolate and candies, ice cream and frozen
desserts, doughnuts and muffins, French fries, potato chips,
nachos and other salty snacks, alcohol, fruit-flavored drinks,
soft drinks, sports and energy drinks and sweetened hot or
cold drinks. With the exception of alcohol, and a few foods
with standards of identity (such as ice cream), the majority of
these foods are eligible to be fortified. Therefore, Health
Canadas proposed discretionary fortification policy is at
odds with national dietary recommendations. The apparent
contradiction between the kinds of foods slated for nutrient
additions under the proposed discretionary fortification
policy and those recommended in Canadas Food Guide is
not surprising, given the very different goals underpinning
these two initiatives. Although the food guide is meant to
provide Canadians with guidelines for a food intake pattern
that will meet nutrient requirements and minimize the risk
of chronic disease (Health Canada, 2007a), the discretionary
fortification policy was not intended, or expected, to
improve Canadians micronutrient intakes (Health Canada,
2005). Concerns about the nutritional quality of foods
eligible for discretionary fortification were raised in the early
stages of policy development, prompting consideration of
the exclusion of foods with components that may increase
risks to health (for example, foods high in sodium, saturated
or trans fat) or foods that do not contribute substantially to
micronutrient intake (Health Canada, 2003). However,
Health Canada concluded that applying these exclusion
criteria would greatly limit the variety of foods eligible for
fortification, which would ultimately restrict trade and
innovation, and thus these exclusion criteria were not
retained in the final policy proposal (Health Canada,
2005). This lack of congruence between public health goals
and nutrition policies is not unique to Canada. Despite
ongoing efforts to promote healthy eating, a recent Amer-
ican supermarket survey found that almost half of the
products using food label marketing strategies (primarily
nutrient content claims) were high in saturated fat, sodium
and/or sugar (Colby et al., 2010).
Addition of vitamins and minerals to foods
JE Sacco and V Tarasuk
318
European Journal of Clinical Nutrition
Implicit in concerns about the dietary quality of foods
eligible to be fortified are two assumptions: (1) that
manufacturers will use the addition of nutrients as a means
to promote their products and (2) that this will lead to
increased consumption of the foods eligible to be fortified.
The link between discretionary fortification and product
promotion is evident in the levels of nutrient addition
permitted under Health Canadas proposed policy; by design,
discretionarily fortified foods will qualify for front-of-
package nutrient content claims highlighting these products
as a good or excellent source of the permitted nutrients.
Although it seems unlikely that manufacturers will volunta-
rily add nutrients to foods unless this confers a market
advantage for them, there is limited published evidence of
the effect of discretionary fortification on product sales or
food consumption patterns. A 1987 study documented an
increase in market share with increased nutrition messaging
in the United States (Levy and Stokes, 1987), but since then,
the use of nutrition marketing on food labels has become
much more prevalent (Elliott, 2008; Colby et al., 2010). Even
if discretionary fortification does not lead to increased
consumption of fortified foods, we have no reason to expect
that product promotion on the basis of nutrient additions
will discourage consumption of these foods. Insofar as
discretionary fortification functions to reinforce existing
dietary patterns, this policy will neither improve dietary
energy density nor address the widespread low fruit,
vegetable and fiber intakes in Canada (Garriguet, 2007b;
Health Canada, 2007b), which are believed to be important
risk factors for obesity (He et al., 2004) and chronic disease
(He et al., 2004, 2006; Hung et al., 2004; Institute of Medicine
(IOM), 2005; Dauchet et al., 2009).
The development of discretionary fortification policy
internationally seems to be largely focused on preventing
excessive nutrient intakes (Health Canada, 2005; Coppens
et al., 2006). As discussions to develop international
standards for discretionary fortification continue (Codex
Alimentarius Commission, 2007), it is important that we
understand the broader public health implications of
discretionary fortification policies on food consumption
patterns, particularly in the context of a growing prevalence
of obesity.
Conflict of interest
The authors declare no conflict of interest.
Acknowledgements
We gratefully acknowledge Dr George Beaton for his
invaluable contributions to this paper. Jocelyn E Sacco holds
a Canadian Institutes of Health Research (CIHR) Fellowship
in Public Health Policy, and a CIHR Canada Graduate
Scholarship Doctoral Award.
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320
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