Examining the effects of increased vitamin D fortification on dietary inadequacy in Canada.
Shakur, Yaseer A. ; Lou, Wendy ; L'Abbe, Mary R. 等
Food fortification has played an important role for decades in
ensuring that Canadians' nutrient requirements are met, and perhaps
the most successful food fortification campaign was the addition of
vitamin D to milk to eradicate rickets in the 1940s. (1) While poor
skeletal health remains an important consequence of vitamin D
deficiency, in recent years there has been a growing body of evidence
suggesting that vitamin D deficiency may be associated with several
other negative consequences, including cancer, asthma, cardiovascular
disease, type 2 diabetes, negative pregnancy outcomes and autoimmune
diseases. (2,3) Nonetheless, skeletal health was the outcome used by the
Institute of Medicine (IOM) to set the Dietary Reference Intakes (DRIs),
which were recently raised significantly for most age groups. (4)
Analysis of Canadian Community Health Survey 2004 (CCHS) data shows
that in all age/sex groups over 75% of Canadians consume inadequate
vitamin D from food sources. (5) Furthermore, Whiting et al. used
2007-2009 Canadian Health Measures Survey data to show that over 25% of
Canadians have serum 25hydroxyvitamin D [25(OH)D] <50 nmol/L,
although 50 nmol/L is the biochemical level of vitamin D thought to be
comparable with the corresponding Recommended Dietary Allowance (RDA).
(6) These biochemical estimates of inadequacy are lower than the dietary
estimates possibly because the body endogenously synthesizes vitamin D
from exposure to UVB (ultraviolet B) light in the summer months. (4) The
authors also reported higher 25(OH)D levels in the summer compared with
winter and among Whites compared with non-Whites. In fact, approximately
two thirds of Canadians have serum 25(OH)D <75 nmol/L, (7) a level
thought to be desirable for overall health benefits and disease
prevention. (8)
Authors of a recent review have called for an urgent need to
increase vitamin D status among Canadians, (9) as vitamin D deficiency
is estimated to cost $14.4 billion annually in Canada. (9) One possible
solution to improve vitamin D status among Canadians is to increase its
fortification in the food supply. (10) Currently, mandatory vitamin D
fortification in Canada covers only fluid milk (2.6-2.8 [micro]g/250 mL)
and margarine (13.25 [micro]g/100 g); (11) it may be added on a
voluntary basis to a few other food items, including orange juice and
yeast-leavened bakery products. (12) Canada's Food Guide (CFG)
recommends that all Canadians consume 2-4 Milk and Alternatives servings
daily, (13) mainly to achieve adequate calcium and vitamin D intakes.
(14) In its directional statements appearing beside the number of
servings, the CFG also recommends that Canadians have 500 mL (2 cups) of
milk for adequate vitamin D. This would mean that for many age groups
(particularly young children and adults aged 19-50), all their Milk and
Alternatives servings would have to come from fluid milk or a fortified
soy beverage, rather than the other options shown in the CFG. While
50%-70% of adults and 53%-80% of children aged 4-18 years consume milk
daily, (15,16) many Canadians choose their Milk and Alternatives
servings from non-milk foods such as yogurt and cheese. Therefore, the
objective of this analysis was to conduct dietary modelling to
investigate the impact on Canadians' intakes of adding vitamin D to
cheese and yogurt and of increasing the fortification levels in milk.
METHODS
Data source and subjects
For this analysis, we used dietary intake data from the 2004 CCHS
2.2, a nationally representative cross-sectional survey with the most
recent data on dietary intake in the population. (17) The CCHS 2.2 is
described in detail elsewhere. (17) We included data from all
nonpregnant, non-lactating respondents [less than or equal to] 1 year,
which led to a final sample of 34,381 subjects. The analyses were
stratified by sex and age groups as defined in the IOM's DRI. (18)
Ethics approval for this study was obtained from the Research Ethics
Board at the University of Toronto.
Food intake data collection
The CCHS 2.2 employed a modified version of the US Department of
Agriculture's (USDA) Automated Multiple Pass Method for 24-h food
recall, and approximately one third of respondents were reinterviewed to
estimate usual (long-term) intake. (17) The nutrient composition of
foods consumed, as reported in the CCHS 2.2, was based on the Canadian
Nutrient File (CNF) version 2001b, (19) which itself was primarily
derived from the USDA Nutrient Database for Standard Reference, Release
13. (20)
Vitamin D modelling
We simulated the addition of vitamin D to the diet by first
identifying foods to be modelled, followed by accessing each food record
of each respondent in our sample and identifying which of their consumed
food items were candidates to be fortified. We then adjusted the vitamin
D content of candidate foods and summed up each respondent's total
vitamin D intake.
Identifying foods to be modelled
We used CNF data along with food composition data in the CCHS 2.2
files to identify milk, cheese and yogurt foods as candidates to be
fortified. The Nutrition Surveillance System food codes were used as
identifiers to link the foods back to those consumed in the 24-h dietary
recalls in the CCHS 2.2. For mixed dishes that contained milk, cheese or
yogurt, the amount of milk, cheese or yogurt in the dish was estimated
according to the composition of the mixed dish.
Modelling scenarios
The analyses were conducted using the schedule M standard reference
amounts as the serving size, (21) as these are the serving sizes used in
the Canadian Food and Drug Regulations.
Model 1: This model served as a reference against which the
fortification scenarios were compared. We used vitamin D intake data as
reported in the CCHS 2.2 with one modification: on the basis of the 2011
Interim Marketing Authorization allowing vitamin D addition to
yeast-leavened bakery products, we modelled vitamin D in these products
by adding 2.25 [micro]g/100 g. (12) The remaining models all included
this modification in addition to their individual adjustments.
Model 2: Cheese and yogurt were modelled to contain 25% (1.25
ug/serving) of the current Recommended Daily Intake (RDI) of 5
[mircro]g,(22) and milk was left at 2.7 [micro]g/250 mL. The RDI is the
amount of a vitamin or mineral nutrient established by the Canadian Food
and Drug Regulations for the purposes of nutritional labelling and
establishing nutrient content claims. (11)
Model 3: Milk, cheese and yogurt were modelled to contain 25% (3.75
[micro]g/serving) of the new proposed RDI of 15 [micor]g, (23) the
labelling level that would correspond to the new higher DRIs for vitamin
D.
Model 4: Milk was modelled at 45% (6.75 [micro]g/serving) of new
proposed RDI, and cheese and yogurt were modelled at 25% (3.75
ug/serving) of the new proposed RDI of 15 [micro]g. (23)
Model 5: Milk, cheese and yogurt were modelled to contain 45% (6.75
[micro]g/serving) of the new proposed RDI of 15 [micro]g.23
Mature market scenario
The above models all mimicked fortification scenarios assuming 100%
compliance with fortification. However, under voluntary fortification,
for mature market scenarios (24) it is unlikely that all cheeses and
yogurts would be fortified with vitamin D, resulting in consumers not
always choosing vitamin D-fortified yogurts and cheeses. Therefore,
assuming one third compliance, we used simulations to fortify 33% of
cheeses and yogurts from models 2 to 5 (i.e., the scenarios in which
cheeses and yogurts are modelled) and reran the analyses for these
models.
Estimation of the prevalence of inadequacy and intakes >UL
The IOM's recently published revised DRI values for vitamin D
were adopted when estimating the prevalence of inadequacy and percentage
of intakes >UL. (4) The prevalence of inadequacy for vitamin D was
estimated using the Estimated Average Requirement (EAR) cut-point
method. (18) We also estimated the proportion of individuals with usual
vitamin D intakes >UL. Recognizing the limitations of using the UL as
a strict risk assessment cut-off, we merely infer that intakes below the
UL are safe. (25)
Statistical analysis
All analyses were performed with the SAS software (version 9.2; SAS
Institute Inc, Cary, NC). SIDE (version 1.11, Department of Statistics
and Center for Agricultural and Rural Development, Iowa State
University) was used to estimate the respondents' usual (long-term)
vitamin D intakes from the second 24-h recall in a subset of
respondents, as others have described previously. (26) Full
distributions of intakes can be found in Appendix 1 Supplementary Tables
2 to 10. The SIDE program was also used to estimate the prevalence of
inadequacy and percentage of intakes >UL among all respondents.
Since the sampling design for the CCHS 2.2 was complex and
multi-stage, variance estimation for these analyses was calculated using
the bootstrap balanced repeated replication technique.
Five hundred replicate sample survey weights were generated each by
random selection, with replacement, from the original sample, and then
all the performed adjustments were applied to this selected sample. A
p-value <0.05 was considered statistically significant in all
analyses.
RESULTS
Under modelling scenarios 4 and 5, there was a doubling of mean
vitamin D intakes when compared with model 1, and several sex and age
subgroups nearly tripled their mean intake in model 5 (Table 1). Model 5
represented the greatest increase in vitamin D intake over model 1, and
males aged 14-18 showed the greatest increase in vitamin D intake, from
9 [micro]g in model 1 to 25.6 [micro]g in model 5. When mature market
scenario was assumed, the effect of each model was dampened (Table 2),
but there was still a doubling of intakes for the majority of sex and
age subgroups under modelling scenario 5 when compared with model 1. The
increase in vitamin D intake under each scenario led to an expected
decrease in the prevalence of vitamin D inadequacy (Figure 1). For
models 4 and 5, all sex and age subgroups had a prevalence of inadequacy
less than 50%, and it reached below 10% among children 1-13 and males
14-30 years old in model 5. As expected, when mature market scenario was
assumed, the decrease in prevalence of inadequacy was diminished
compared with the full modelling scenarios, and it was only in model 5
that all groups had a prevalence of inadequacy less than 50% (Figure 2).
The percentage of intakes >UL was zero for all groups under all
modelling scenarios (Appendix 1 - Supplementary Table 1). In fact, the
95th percentile intake never reached above 50 ug (2000 IU) for any sex
and age subgroup under any modelling scenario, which is half of the new
UL (100 ug or 4000 IU) (Appendix 1 Supplementary Tables 2 to 10).
DISCUSSION
This is the first study using nationally representative Canadian
data to model the effects of fortifying cheese and yogurt in addition to
milk on vitamin D intakes and inadequacy among Canadians. We observed
doubling of intakes in modelling scenarios 4 (6.75 [micro]g/serving of
milk; 3.75 [micro]g/serving of cheese and yogurt) and 5 (6.75
[micro]g/serving of milk, cheese and yogurt) with a concurrent drop in
the prevalence of inadequacy to below 50% in both models. Also, assuming
a mature market scenario for cheese and yogurt under which only one
third of these products are fortified, the prevalence of inadequacy
still dropped below 50% in model 5. These prevalence estimates are a
sizeable improvement over the current situation, in which the prevalence
of inadequacy is >80% in most sex/age groups. Furthermore, the fact
that none of the modelling scenarios resulted in intakes that approached
the UL indicates that none of the fortification scenarios pose the risk
of excessive intakes among Canadians.
[FIGURE 1 OMITTED]
We chose yogurt and cheese as candidates for vitamin D
fortification because these two foods, along with milk, form the main
items in the Milk and Alternatives Food Group of the CFG. (13) Moreover,
a national survey showed that 31% of men and 49% of women believe that
milk and other milk products contain vitamin D. (27) More specifically,
approximately 30%-40% of Canadians believe that both cheese and yogurt
contain vitamin D.27 Although processors can use fortified milk to make
yogurt and cheese, this practice is not mandatory and tends to result in
much lower vitamin D levels than those found in milk. The CFG currently
recommends "having 500 mL (2 cups) of milk every day for adequate
vitamin D". (13) Thus, if cheeses and yogurts contained vitamin D,
this directional statement can be broadened to include cheeses and
yogurts, thereby providing more options for Canadians to consume
adequate vitamin D. Yogurt has been fortified with vitamin D in Finland
(0.5 [micro]g/100g) since 2003, (28) and recent biochemical analyses
have shown that vitamin D can be added to both yogurt and hard cheeses
without compromising its stability. (29,30)
While it is well established that food fortification can improve
nutrient status, there is always a need to balance the benefits of
increased intake with possible risks of excess. (1) In the presence of
mandatory fortification of milk and margarine and optional fortification
of other products, the fact that there is still widespread prevalence of
dietary inadequacy and approximately a quarter of Canadians with
suboptimal serum 25(OH)D levels indicates that the current program is
ineffective and there is a need for increased intakes. We have shown
here that unless there is increased food fortification with vitamin D
(in this case, with higher levels in milk, and fortification of cheese
and yogurt), the majority of Canadians will continue to consume
inadequate amounts from food alone and, as a result, there is likely to
be no improvement in vitamin D status, especially in winter, when there
is inadequate endogenous production of vitamin D from exposure to UVB
light. Furthermore, no risk of intakes >UL under any fortification
scenario indicates that increased fortification can result in the
substantial benefit of increased intake without the risk of excess.
While supplemental vitamin D consumption does increase vitamin D
intake and improve vitamin D status, (5,6) only 28%-31% of Canadians
consume a supplement containing vitamin D. (5,6) Furthermore, supplement
use is associated with healthier lifestyles and higher socio-economic
backgrounds, and therefore supplements are probably not consumed by
those who need them the most to overcome dietary inadequacies. (31) In
these analyses, we did not include supplemental vitamin D intake.
However, even under model 5, which yielded the highest vitamin D intake,
adding as much as 50 [micro]g (2000 IU) of supplemental vitamin D to the
diet would not result in a total intake >UL.
[FIGURE 2 OMITTED]
Our study now provides tangible evidence supporting the
recommendations of an Expert Advisory Committee to Health Canada,
demonstrating a potential lower prevalence of inadequacy with the
addition of vitamin to more foods without a risk of excessive intakes.
(32) A limitation of this study is that we used the CCHS 2.2, in which
dietary intake data were collected eight years before our analysis.
However, we are unaware of literature suggesting that Canadians'
dietary patterns have changed since that time and, furthermore, the CCHS
2.2 remains our most recent nationally representative dietary intake
data collection. A second limitation is that we estimated vitamin D
inadequacy on the basis of dietary intake data alone and did not
investigate clinical parameters of deficiency, because the CCHS 2.2 does
not contain biochemical data. However, any discrepancy between estimates
of inadequacy based on diet and estimates derived from clinical measures
is only likely to occur in the summer months, when there is endogenous
vitamin D synthesis from sun exposure. Also, this study limited
fortification vehicles to dairy products, as we believe that the first
step in expanding the current fortification program is to fortify
non-milk dairy products. In the future, if vitamin D inadequacy
continues to be a problem in Canada, it is possible to consider staple
foods from the other three food groups.
CONCLUSION
Vitamin D fortification of yogurt and cheese, along with increased
fortification of milk, has the potential to double dietary intakes of
vitamin D in Canada and lower the documented high prevalence of
inadequacy among Canadians. Furthermore, we show here that
fortification, even at levels of 6.75 [micro]g/serving, will not lead to
intakes anywhere near the UL. Giving the growing evidence suggesting
several other negative consequences of suboptimal vitamin D status, in
addition to poor skeletal health, and the documented economic burden of
poor vitamin D status, increased vitamin D fortification is a policy
well worth pursuing in Canada. Such fortification would provide a more
inclusive Milk and Alternatives CFG food group with respect to vitamin
D, ensuring that cheese and yogurt, the most commonly consumed dairy
products after fluid milk, also contain vitamin D at comparable levels.
Acknowledgements: This study was funded by a grant from Dairy
Farmers of Canada. Dairy Farmers of Canada had no role in the
implementation, analysis or interpretation of the data. Yaseer Shakur
also received funding from a Comprehensive Research Experience for
Medical Students scholarship from the Faculty of Medicine, University of
Toronto.
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Submitted to Health Canada, January 2012.
Received: June 14, 2013
Accepted: February 12, 2014
Yaseer A. Shakur, PhD, [1] Wendy Lou, PhD, [2] Mary R. L'Abbe,
PhD [1]
Author Affiliations
[1.] Department of Nutritional Sciences, Faculty of Medicine,
University of Toronto, Toronto, ON
[2.] Dalla Lana School of Public Health, University of Toronto,
Toronto, ON Correspondence: Mary R. L'Abbe, Earle W. McHenry
Professor and Chair, Department of Nutritional Sciences, Faculty of
Medicine, University of Toronto, FitzGerald Bldg, Rm 315, 150 College
St, Toronto, ON M5S 3E2, Tel: 416-978-7235,
E-mail:
[email protected]
Conflict of Interest: None to declare.
Table 1. Mean usual vitamin D intake ([micro]g/day) stratified by sex
and age subgroups based on modelling full fortification scenarios *
Sex Age (y) EAR ** N
Both 1-3 10 2193
4-8 10 3343
Male 9-13 10 2149
14-18 10 2397
19-30 10 1897
31-50 10 2750
51-70 10 2725
>70 10 1601
[less than or 10 8973
equal to] 19
Female 9-13 10 2043
14-18 10 2346
19-30 10 1915
31-50 10 2851
51-70 10 3407
>70 10 2769
[less than or 10 10,942
equal to] 19
Model 1 Model 2:
([dagger]) ([double dagger])
Sex Age (y) mean (SE) mean (SE)
([dagger]
[dagger])
Both 1-3 7.2 0.1 8.2 0.2
4-8 7 0.1 8.3 0.1
Male 9-13 8.5 0.2 10 0.2
14-18 9 0.2 10.8 0.3
19-30 8 0.2 9.6 0.3
31-50 7.6 0.2 9 0.3
51-70 8.2 0.4 9.3 0.4
>70 7.9 0.4 8.8 0.5
[less than or 7.9 0.2 9.2 0.2
equal to] 19
Female 9-13 6.9 0.2 8 0.2
14-18 6.3 0.2 7.6 0.2
19-30 5.7 0.2 6.9 0.2
31-50 6 0.3 7.1 0.3
51-70 6.4 0.3 7.3 0.3
>70 6.3 0.7 7.1 0.7
[less than or 6.1 0.2 7.1 0.2
equal to] 19
Model 3 Model 4
([section]) ([parallel])
Sex Age (y) mean (SE) mean (SE)
Both 1-3 12.4 0.3 18 0.4
4-8 12.5 0.2 17.1 0.3
Male 9-13 14.8 0.3 20.3 0.5
14-18 16.2 0.4 21.4 0.5
19-30 14.2 0.4 17.8 0.5
31-50 12.6 0.4 15.5 0.6
51-70 12.1 0.5 14.7 0.5
>70 11.2 0.6 14.4 0.8
[less than or 12.5 0.2 15.6 0.3
equal to] 19
Female 9-13 11.9 0.3 16 0.4
14-18 11.4 0.3 15 0.4
19-30 10.3 0.3 13.1 0.4
31-50 10.1 0.4 12.6 0.4
51-70 10 0.3 12.4 0.3
>70 9.3 0.7 12.1 0.7
[less than or 9.9 0.2 12.5 0.2
equal to] 19
Model 5
([paragraph])
Sex Age (y) mean (SE)
Both 1-3 20.7 0.4
4-8 20.2 0.4
Male 9-13 23.8 0.6
14-18 25.6 0.6
19-30 21.8 0.7
31-50 18.5 0.7
51-70 17 0.6
>70 15.9 0.9
[less than or 18.3 0.4
equal to] 19
Female 9-13 19 0.5
14-18 18.1 0.5
19-30 16 0.6
31-50 15.1 0.5
51-70 14.6 0.4
>70 13.6 0.7
[less than or 14.7 0.3
equal to] 19
* Model scenarios were conducted using Schedule M reference
amounts21 as the serving size.
([dagger]) This model served as the baseline model and it included
current vitamin D fortification practices and the 2011 Interim
Market Authorization, i.e., simulation of yeast-leavened bakery
products to contain 2.25 [micro]g of vitamin D per 100 g of
product.
([double dagger]) Milk was simulated at 2.7 [micro]g of vitamin D
per 250 mL serving, and cheeses and yogurts were simulated to
contain 1.25[micro]g of vitamin D per serving.
([section]) Milk, cheeses and yogurts were simulated to contain
3.75 jg of vitamin D per serving.
([parallel]) Milk was simulated at 6.75 [micro]g of vitamin D per
250 mL serving, and cheeses and yogurts were simulated to contain
3.75 [micro]g of vitamin D per serving.
([paragraph]) Milk, cheeses and yogurts were simulated to contain
6.75 [micro]g of vitamin D per serving.
** Estimated average requirement ([micro]g).
([dagger][dagger]) All standard errors were calculated using the
bootstrap method for variance estimation.
Table 2. Mean usual vitamin D intake ([micro]g/day) stratified by sex
and age subgroups based on modelling mature market scenarios *
Sex Age (y) EAR** N
Both 1-3 10 2193
4-8 10 3343
Male 9-13 10 2149
14-18 10 2397
19-30 10 1897
31-50 10 2750
51-70 10 2725
>70 10 1601
[less than or 10 8973
equal to] 19
Female 9-13 10 2043
14-18 10 2346
19-30 10 1915
31-50 10 2851
51-70 10 3407
>70 10 2769
[less than or 10 10,942
equal to] 19
Model 1 Model 2:
([dagger]) ([double dagger])
Sex Age (y) mean (SE) mean (SE)
([dagger]
[dagger])
Both 1-3 7.2 0.1 7.6 0.1
4-8 7 0.1 7.5 0.1
Male 9-13 8.5 0.2 9.1 0.2
14-18 9 0.2 9.7 0.2
19-30 8 0.2 8.5 0.2
31-50 7.6 0.2 8.2 0.3
51-70 8.2 0.4 8.7 0.4
>70 7.9 0.4 8.5 0.5
[less than or 7.9 0.2 8.5 0.2
equal to] 19
Female 9-13 6.9 0.2 7.3 0.2
14-18 6.3 0.2 6.7 0.2
19-30 5.7 0.2 6.2 0.2
31-50 6 0.3 6.5 0.3
51-70 6.4 0.3 6.8 0.3
>70 6.3 0.7 6.7 0.7
[less than or 6.1 0.2 6.6 0.2
equal to] 19
Model 3 Model 4
([section]) ([parallel])
Sex Age (y) mean (SE) mean (SE)
Both 1-3 10.3 0.2 15.9 0.4
4-8 10 0.2 14.5 0.3
Male 9-13 12 0.3 17.4 0.4
14-18 12.7 0.3 17.9 0.5
19-30 10.9 0.3 14.6 0.5
31-50 10.1 0.4 13 0.6
51-70 10.2 0.4 12.9 0.5
>70 10 0.5 13.2 0.8
[less than or 10.3 0.2 13.4 0.3
equal to] 19
Female 9-13 9.5 0.2 13.6 0.4
14-18 8.9 0.2 12.5 0.4
19-30 7.9 0.2 10.6 0.4
31-50 8 0.3 10.5 0.4
51-70 8.2 0.3 10.7 0.3
>70 8.1 0.7 10.8 0.7
[less than or 8.1 0.2 10.6 0.2
equal to] 19
Model 5
([paragraph])
Sex Age (y) mean (SE)
Both 1-3 16.6 0.4
4-8 15.6 0.3
Male 9-13 18.7 0.4
14-18 19.4 0.5
19-30 16 0.5
31-50 14 0.6
51-70 13.7 0.5
>70 13.8 0.7
[less than or 14.3 0.3
equal to] 19
Female 9-13 14.6 0.5
14-18 13.5 0.4
19-30 11.7 0.4
31-50 11.4 0.4
51-70 11.4 0.3
>70 11.4 0.7
[less than or 11.4 0.2
equal to] 19
* Model 1 is the comparison model and therefore based on a full
fortification scenario; in Models 2-5, mature market scenarios were
used assuming fortification of 33% of cheeses and yogurts; model
scenarios were conducted using Schedule M reference amounts21 as
the serving size.
([dagger]) This model included current vitamin D fortification
practices and the 2011 Interim Market Authorization, i.e.,
simulation of yeast-leavened bakery products to contain 2.25
[micro]g of vitamin D per 100 g of product.
([double dagger]) Milk was simulated at 2.7 [micro]g of vitamin D
per 250 mL serving, and cheeses and yogurts were simulated to
contain 1.25 [micro]g of vitamin D per serving.
([section]) Milk, cheeses and yogurts were simulated to contain
3.75 [micro]g of vitamin D per serving.
([parallel]) Milk was simulated at 6.75 [micro]g of vitamin D per
250 mL serving, and cheeses and yogurts were simulated to contain
3.75 [micro]g of vitamin D per serving. U Milk, cheeses and yogurts
were simulated to contain 6.75 [micro]g of vitamin D per serving.
** Estimated average requirement ([micro]g).
([dagger][dagger]) All standard errors were calculated using the
bootstrap method for variance estimation.
