The effect of consuming voluntarily fortified food and beverages on usual nutrient intakes in the Canadian population
Background: In Canada, regulatory changes have expanded marketing opportunities for voluntarily fortified products (VFPs), with micronutrient additions permitted at levels well in excess of human requirements.
Objective: To examine how the consumption of VFPs relates to usual nutrient intakes in the Canadian population.
Design: The 2015 Canadian Community Health Survey comprises single 24-h dietary intake recalls on a population-representative sample of 20,487 individuals aged 1 year and older, with second recalls on a subset of 7,608. The intake data included 15 food codes denoting VFP (e.g. energy drinks, fortified beverages, cereals, and bars). We assessed VFP consumption and estimated usual intake distributions for riboflavin, niacin, zinc, and vitamins A, B6, B12, and C for VFP consumers and non-consumers 14–50 years old (n = 8,442) using the National Cancer Institute method. We applied the ‘shrink and add’ method to estimate usual intakes among supplement users and assessed apparent benefits and risks by comparing usual intake distributions to EARs and ULs.
Results: Only 2.4% of the population reported any consumption of VFP on the first 24-h recall. VFP consumers were overrepresented in the upper quartile of population intake distributions for niacin, riboflavin, vitamin B6, vitamin B12, and zinc. The median usual intakes of VFP consumers were 24–111% higher than the median usual intakes of non-consumers, and VFP consumers had significantly lower prevalence of inadequacy for riboflavin and vitamins A, B6, B12, and C. Irrespective of VFP consumption, usual intake distributions reached the ULs for vitamin A and zinc with the addition of supplement intakes.
Discussion: Given the limited differentiation of VFP in this survey, we have likely underestimated nutrient exposure levels.
Conclusions: VFP consumption was associated with elevated usual nutrient intakes, but we found limited evidence that it protected consumers from nutrient inadequacies or propelled intakes above tolerable upper levels.
- Hennessy A, Walton J, Flynn A. The impact of voluntary food fortification on micronutrient intakes and status in European countries: a review. Proc Nutr Soc 2013; 72: 433–40. doi: 10.1017/S002966511300339X
- Casala E, Mattys C, Peter S, Baka A, Kettler S, McNulty B, et al. Monitoring and addressing trends in dietary exposure to micronutrients through voluntarily fortified foods in the European Union. Trends Food Sci Technol 2014; 37: 152–61. doi: 10.1016/j.tifs.2014.03.001
- Martineau C, Barber J, Bertinato J, Brooks S, Chao E, Daoust J, et al. Proposed approach to setting maximum levels for vitamins, mineral nutrients, and amino acids in beverages, beverage mixes and concentrates, powders, bars, and confectionaries eligible for temporary marketing authorization in Canada. Int Food Risk Anal J 2014; 4(3): 1–8. doi: 10.5772/58719
- Codex Alimentarius Commission. General principles for the addition of essential nutrients to foods. Rome: Food and Agriculture Organization of the United Nations and World Health Organization;1991. Report No.: CAC/GL 09-1987.
- Canada. Natural health product regulations. Ottawa, ON: Government of Canada; 2003. Report No.: 137 (13).
- Food Directorate – Health Products and Food Branch, Health Canada. Food Directorate. Category specific guidance for temporary marketing authorization caffeinated energy drinks. Health Canada; 2013. Available from https://www.canada.ca/content/dam/hc-sc/migration/hc-sc/fn-an/alt_formats/pdf/legislation/guide-ld/guidance-caf-drink-boiss-tma-amt-eng.pdf
- Food Directorate – Health Products and Food Branch, Health Canada. Food Directorate. General guidance document for temporary marketing authorization for foods. Health Canada; 2013 [updated 2013 May]. Available from: http://www.hc-sc.gc.ca/fn-an/legislation/guide-ld/food-market-author-marche-aliment-eng.php
- Food Directorate – Health Products and Food Branch. Health Canada. Category specific guidance for temporary marketing authorization: supplemented food. Health Canada; 2016. Available from: https://www.canada.ca/en/health-canada/services/food-nutrition/legislation-guidelines/guidance-documents/category-specific-guidance-temporary-marketing-authorization-supplemented-food.html
- Sacco J. Food fortification in Canada. In: Preedy V, Srirajaskanthan R, Patel V, editors. Handbook of food fortification and health: from concepts to public health applications. New York NY: Humana Press, 2013; p. 1.
- Zamani R, Tarasuk V. Micronutrient fortification of caffeinated energy drinks and supplemented foods marketed in Canada. Appl Physiol Nutr Metab 2020; 45(10): 1178–83. doi: 10.1139/apnm-2019-0918
- Dachner N, Mendelson R, Sacco J, Tarasuk V. An examination of the nutrient content and on-package marketing of novel beverages. Appl Physiol Nutr Metab 2015; 40(2): 191–8. doi: 10.1139/apnm-2014-0252
- Euromonitor International. Energy drinks in Canada – analysis. Euromonitor International; 2019.
- Czoli C, Jones A, Hammond D. Trends in sugary drinks in Canada, 2004 to 2015: a comparison of market sales and dietary intake data. Public Health Nutr 2019; 22(15): 2723–8. doi: 10.1017/S1368980019001654
- Berner L, Keast D, Bailey R, Dwyer JT. Fortified foods are major contributors to nutrient intakes in diets of US children and adolescents. J Acad Nutr Diet 2014; 114(7): 1009–1022.e8. doi: 10.1016/j.jand.2013.10.012
- Fulgoni V, Keast D, Bailey R, Dwyer J. Foods, fortificants, and supplements: where do Americans get their nutrients? J Nutr 2011; 141(10): 1847–54. doi: 10.3945/jn.111.142257
- Murphy M, Spungen J, Barraj L, Bailey R, Dwyer JT. Revising the daily values may affect food fortification and in turn nutrient intake adequacy. J Nutr 2013; 143(12): 1999–2006. doi: 10.3945/jn.113.181099
- Hannon E, Kiely M, Flynn A. The impact of voluntary fortification of foods on micronutrient intakes of Irish adults. Br J Nutr 2007; 97(1177): 1186. doi: 10.1017/S0007114507669207
- Sacco J, Kirkpatrick S, Dodd KW, Tarasuk V. Voluntary food fortification in the United States: potential for excessive intakes. Eur J Clin Nutr 2013; 67(6): 592–7. doi: 10.1038/ejcn.2013.51
- Health Canada. Reference guide to understanding and using the data. 2015 Canadian Community health survey-nutrition. Ottawa ON: Health Canada; 2017. Catalogue No.: H164-208/2017E-PDF.
- Blanton C, Moshfegh A, Baer D, Kretsch MJ. The USDA automated multiple-pass method accurately estimates group total energy and nutrient intake. J Nutr 2006; 136(10): 2594–9. doi: 10.1093/jn/136.10.2594
- Government of Canada. List of foods that have received temporary marketing authorization letters 2019 [updated 2019-09-30]. Available from: https://www.canada.ca/en/health-canada/services/food-nutrition/legislation-guidelines/acts-regulations/lists-foods-that-have-received-temporary-marketing-authorization-letters.html
- Health Canada. 2015 Canadian Community Health Survey (CCHS) – Nutrition: user guide. Government of Canada; 2017.
- Institute of Medicine. Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids. Washington, DC: National Academy Press; 2005.
- Garriguet D. Accounting for misreporting when comparing energy intake across time in Canada. Health Rep 2018; 29(5): 3–12.
- Goldberg GR, Black AE, Jebb SA, Cole TJ, Murgatroyd PR, Coward WA, et al. Critical evaluation of energy intake data using fundamental principles of energy physiology: 1. Derivation of cut-off limits to identify under-recording. Eur J Clin Nutr 1991; 45: 569–81.
- Black AE, Prentice AM, Goldberg GR, Jebb SA, Bingham SA, Livingstone MBE, et al. Measurements of total energy expenditure provide insights into the validity of dietary measurements of energy intake. J Am Diet Assoc 1993; 93: 572–9. doi: 10.1016/0002-8223(93)91820-G
- McCrory MA, Hajduk C, Roberts SB. Procedures for screening out inaccurate reports of dietary energy intake. Public Health Nutr 2002; 5: 873–82. doi: 10.1079/PHN2002387
- Health Canada. Canadian Nutrient File (CNF): Health Canada; 2015. Available from: https://food-nutrition.canada.ca/cnf-fce/index-eng.jsp
- Harb J, Taylor Z, Khullar V, Sattari M. Rare cause of acute hepatitis: a common energy drink. BMJ Case Reports 2016;2016:bcr2016216612. doi: 10.1136/bcr-2016-126612
- Zhang J, Yu K. What’s the relative risk? A method for correcting the odds ratio in cohort studies of common outcomes. JAMA 1998; 280: 1690–1. doi: 10.1001/jama.280.19.1690
- Cole T, Altman DG. Statistics notes: percentage differences, symmetry, and natural logarithms. BMJ 2017; 358: J3683. doi: 10.1136/bmj.j3683
- Bailey R, Dodd KW, Gahche J, Dwyer JT, Cowan A, Jun S, et al. Best practices for dietary supplement assessment and estimation of total usual nutrient intakes in population-level research monitoring. J Nutr 2019; 149: 181–97. doi: 10.1093/jn/nxy264
- Institute of Medicine. Dietary reference intakes for thiamin, riboflavin, niacin, vitamin B6, folate, vitamin B12, pantothenic acid, biotin, and choline. Washington, DC: National Academy Press; 1998.
- Institute of Medicine. Dietary reference intakes for vitamin C, vitamin E, selenium, and carotenoids. Washington, DC: National Academy Press; 2000.
- Institute of Medicine. Dietary reference intakes: vitamin A, vitamin K, arsenic, boron, chromium, copper, iodine, iron, manganese, molybdenum, nickel, silicon, vanadium, and zinc. Washington, DC: National Academy Press; 2002.
- Rasmussen S, Andersen N, Dragsted L, Larsen J. A safety strategy for additions of vitamins and minerals to foods. Eur J Nutr 2006; 45: 123–35. doi: 10.1007/s00394-005-0580-9
- Popkin BM, Hawkes C. Sweetening the global diet, particularly beverages: patterns, trends, and policy responses. Lancet Diabetes Endocrinol 2016; 4(2): 174–87. doi: 10.1016/S2213-8587(15)00419-2
- Heckman M, Sherry K, Gonzalez de Mejia E. Energy drinks: an assessment of their market size, consumer demographics, ingredient profile, functionality, and regulation in the United States. Compr Rev Food Sci Food Saf 2010; 9: 303–17. doi: 10.1111/j.1541-4337.2010.00111.x
- 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; 106: 1640–50. doi: 10.1016/j.jada.2006.07.011
- Tooze JA, Midthune D, Dodd KW, Freedman LS, Krebs-Smith S, 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(10): 1575–87. doi: 10.1016/j.jada.2006.07.003
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