Fortification of foods with additional nutrients does have an impact on kids’ intake of vitamins and minerals, but many children and teens are still not getting adequate nutrition, according to a new U.S. study.

Based on a large national dietary survey, the researchers found that without fortification, the diets of a large number of children and teens would be nutritionally inadequate. With fortification the picture is better, but not perfect.

“Foods with added nutrients (most notably breakfast cereals, enriched grain foods, fluid milks) supplied important amounts of many but not all vitamins and minerals in diets of U.S. children and adolescents,” Louise Berner told Reuters Health in an email.

Berner is a food science and nutrition researcher at Cal Poly State University in San Luis Obispo, California.

Currently, the U.S. Food and Drug Administration requires some fortification of food, such as enriching refined flour with vitamins and iron and adding vitamin A to low- and non-fat milk.

Food manufacturers may also add nutrients to food voluntarily - some brands of orange juice, for example, are fortified with added calcium.

Berner and colleagues wanted to find out both how much of an impact fortification has on kids’ nutrition and determine which foods were providing the added nutrients.

The researchers used data from the National Health and Nutrition Examination Survey to analyze the diets of 7,250 children and adolescents ages 2 to 18 years old.

Berner’s team looked at the types of food eaten and any supplements taken and assessed the nutrient content of each food. Then they assessed how nutritionally adequate each kid’s diet was by seeing whether it met Estimated Average Requirements (EAR).

The EAR is the average daily nutrient intake level estimated to meet the requirement of half the healthy individuals in a particular group based on age or gender.

On average, girls ages 14 to 18 years old were most likely to fall short of the EAR for their age, while boys and girls 2 to 8 years old had the lowest rates of inadequate nutrient intakes.

The study team found that fortified foods contributed half or more of the intakes of vitamin D, thiamin, and folate to children’s diets; 20 to 47 percent of the intakes of vitamin A, vitamin C, riboflavin, niacin, B-6, B-12, and iron; 12 to 18 percent of the intake of zinc; but only 4.5 to 6.6 percent of calcium.

Even with the increased nutrients from fortified sources, a substantial percentage of kids still had intakes of vitamins A, C and D that were less than the EAR for their age and sex.

The fortified foods also did not appear to lead to excessive intakes of any nutrients, which is a concern others have expressed in the past, Berner and her colleagues note in the Journal of the Academy of Nutrition and Dietetics.

The fortified foods that provided the most nutrients were breakfast cereals, milk and milk drinks, breads, rolls and other products made with enriched grains.

“This research study provides a good picture of the contribution of fortified foods to kids’ diets in the U.S.,” Berner said, “but, it should not be misinterpreted as a dietary recommendation to consumers - that was not the intent of the research.”

So many unfortified foods, including fruits, vegetables, meats, fish and so forth, are critically important parts of healthful diets yet are often under-consumed, Berner said.

“But, selectively, I think it makes sense - for example, choosing a fortified breakfast cereal instead of an unfortified one,” she said.

Berner and her coauthors advise consumers to obtain nutrients primarily from foods that are naturally nutrient-dense. And, they point out, not all fortified foods are healthy foods.

“The trouble with fortification is that while it can increase the ‘good,’ it doesn’t necessarily do anything to decrease the ‘bad’,” Dr. David Katz told Reuters Health in an email.

Katz is the founding director of the Prevention Research Center at Yale University School of Medicine and medical director for the Integrative Medicine Center at Griffin Hospital in Derby, CT. He was not involved in the new study.

Katz said there are examples of fortification that are very important no matter what the diet is like. Vitamin D in a population that doesn’t get a lot of sun exposure is perhaps the best example.

Katz said the paper demonstrates that in a culture that eats very poorly, we need fortification to have adequate nutrient intake.

“But what this paper does not address at all is: what would happen if we actually ate well,” he added.

Katz said it’s a mistake to think that preventing nutrient deficiencies with fortified “junk” foods is in any way the same as eating truly good foods.

“Eating a variety of wholesome foods would provide those same nutrients, along with many others, and without the sugar, salt, refined starch, unhealthy oils, excess calories and so on,” Katz said.

SOURCE: Journal of the Academy of Nutrition and Dietetics. Online January 27, 2014.

###

Fortified Foods Are Major Contributors to Nutrient Intakes in Diets of US Children and Adolescents

Design and statistical analyses
Data were from 7,250 respondents 2 to 18 years old in the National Health and Nutrition Examination Survey 2003-2006. Datasets were developed that distinguished nutrient sources: intrinsic nutrients in foods; added nutrients in foods; foods (intrinsic plus added nutrients); and total diet (foods plus supplements). The National Cancer Institute method was used to determine usual intakes of micronutrients by source. The impact of fortification on the percentages of children having intakes less than the Estimated Average Requirement and more than the Upper Tolerable Intake Level was assessed by comparing intakes from intrinsic nutrients to intakes from intrinsic plus added nutrients. Specific food sources of micronutrients were determined as sample-weighted mean intakes of total and added nutrients contributed from 56 food groupings. The percentage of intake from each grouping was determined separately for total and added nutrients.

Results
Without added nutrients, a high percentage of all children/adolescents had inadequate intakes of numerous micronutrients, with the greatest inadequacy among older girls. Fortification reduced the percentage less than the Estimated Average Requirement for many, although not all, micronutrients without resulting in excessive intakes. Data demonstrated the powerful influence of fortification on food-source rankings.

Conclusions
Knowledge about nutrient intakes and sources can help put dietary advice into a practical context. Continued monitoring of top food sources of nutrients and nutrient contributions from fortification will be important.

###

Even in the context of epidemic obesity and dietary excess, numerous shortfall micronutrients have been identified in American diets, including some vitamins and minerals of particular concern for children and adolescents. To help tailor strategies for meeting nutrient recommendations, it is valuable to know what specific foods contribute greatly to micronutrient intakes. Important sources of nutrients in American diets are not necessarily foods that are intrinsically nutrient rich; nutrients can also come from dietary supplements or from foods that are frequently consumed and/or fortified.

Fortification (this term is used generically throughout this article to refer to any addition of nutrients to foods) is one potential means of addressing micronutrient shortfalls. In fact, micronutrients have been added to fortify foods in the United States for more than half a century, and the practice played a major role in virtually eliminating classical nutrient-deficiency diseases, such as rickets and pellagra. At the present time, some fortification is carried out in accordance with specific requirements of the US Food and Drug Administration, such as standards of identity for enriched grain foods or addition of vitamin A to reduced-fat milk to meet nutritional equivalency of whole milk, and other fortification has been termed discretionary because it is done voluntarily and at the discretion of food manufacturers (although, of course, within technological, regulatory, and other constraints). Despite its historical success, fortification has come under scrutiny because of concerns that it could lead to overconsumption of nutrients. However, although fortification has undoubtedly increased vitamin and mineral intakes in the United States, data are lacking on the specific contributions made by fortification of foods with micronutrients5 other than folic acid.

To ascertain the effects of fortification on children’s dietary quality, it is essential to examine the specific sources of nutrients as well as the overall levels of nutrient intake. Subar and colleagues determined which food sources contributed the highest amounts of nutrients to diets of US children in 1989-1991. Although they concluded that fortified foods, especially ready-to-eat (RTE) cereals, made large contributions to intakes of many nutrients, the amounts contributed by added nutrients contained in fortified foods were not specifically examined. There has been a lack of information about the impact of fortification on nutrient adequacy and excess among children in the United States, and what foods are making the largest contributions to intakes of added nutrients.
Author(s) - Louise A. Berner, Debra R. Keast, Regan L. Bailey, Johanna T. Dwyer
Journal of the Academy of Nutrition and Dietetics - 27 January 2014 (10.1016/j.jand.2013.10.012)