Mandatory fortification

The mandatory fortification of margarine with Vitamin A is accomplished by the addition of p-carotene (pro-Vitamin A) and/or Vitamin A esters. The carotene level is adjusted for the desired color and the colorless esters (acetate, palmitate, etc.) are used to standardize the vitamin content. Addition of Vitamin D is optional. Fortification with Vitamin E is not permitted by the U.S. margarine standard, but recently some spreads fortified with Vitamin E have appeared in the marketplace in the United States, and fortification of both margarines and spreads has recently been done in Europe. The naturally occurring Vitamin E content of vegetable oil margarines available in the United States has been reported (227). 

Notes-. Iodine intake expressed as iodine dietary intake and urinary iodine excretion in elderly males (M) and females (F). The early Danish surveys indicate mild-to-moderate iodine deficiency, even among users of dietary supplements. The 68-year-old Danes were also compared to elderly subjects in Iceland with a long-standing relatively high iodine intake. After the mandatory fortification of salt in 2000-2001, the Danish National Survey 2002 indicates a sufficient iodine intake among elderly subjects. N, numbers 7-D R, 7-days food record FFQ, food frequency questionnaire. 

It should be noted that the voluntary program of bread fortification in Tasmania was introduced as an interim measure only. As a result of the re-emergence of iodine deficiency in Austrafia (Gunton et al., 1999 Li et al., 2001, McDonnell et al., 2003, Hynes et al., 2004) and in New Zealand (Thomson et al., 2001, Skeaff et al., 2002, 2003) mandatory fortification of bread with iodized salt is presently being considered by Food Standards Australia New Zealand (FSANZ) (2007). 

Mandatory fortification, preferably universal salt iodization (including all salt used in processed foods), is required to eliminate iodine deficiency in all groups in the population. 

Food Standards Australia and New Zealand. (May, 2007). Proposal P230 Consideration of Mandatory Fortification with Iodine. Key Issues for Consideration at Final Assessment. Gibson, H.B. (1995). Surveillance of Iodine Deficiency Disorders in Tasmania 1949—1984. Department of Health Services, Hobart, Tasmania. 

Urgent measures are needed to improve the iodine status of New Zealanders and mandatory fortification is being considered. 

FSANZ. (2006). Proposal P230 consideration of mandatory fortification with iodine. Canberra, Australia Wellington, New Zealand, Food Standards Australia New Zealand. 

However, a dispute about folate fortification arouse in the last years as the decreasing trend of colon cancer inverted in some countries with mandatory folate fortification since its implementation (Mason et al. 2007). Therefore, many countries in the EU refuse mandatory fortification and favour the consumption of foods endogenously high in folates or increasing folate content in foods, generally. 

In order to estimate reliably the associations of homocysteine with CHD and stroke outcomes, individual participant data were collected from all observational studies of homocysteine with CHD and stroke outcomes for the Homocysteine Studies Collaboration (Homocysteine Studies Collaboration 2002). With individual participant data, the Homocysteine Studies Collaboration meta-analysis was able to examine the shape and strength of association of homocysteine with vascular disease after adjustment for bias and confounding due to other risk factors (Homocysteine Studies Collaboration 2002). After excluding individuals with prior disease at enrolment and adjustment for smoking, blood pressure and cholesterol, a 25% lower usual i.e. longterm) homocysteine concentration (about 3 pmol/L, a difference typically achieved by folic add supplementation in populations without mandatory fortification of grain products with folic acid) was associated with an 11% (95% Cl 4-17%) lower risk of CHD and a 19% (5-31%) lower risk of stroke (Homocysteine Studies Collaboration 2002). 

A detailed description of microbial synthesis of the three most relevant B-group vitamins (riboflavin, folate, and cobalamin) by LAB has been discussed in detail previously (LeBlanc et al. 2010a) and will not be the focus of this chapter. Here, the most recent applications of beneficial microorganisms in order to increase the concentration of vitamins through microbial biosynthesis will be discussed as an economically attractive alternative to mandatory fortification of foods. 

Prior to mandatory fortification of fiour-based products. 

C Schorah, D Buss. Should flour fortification with folic acid be mandatory to reduce the incidence of neural Lube defects BNF Nutr Bull 20 292-301, 1995. 

Fortification of margarine and dairy products with vitamin D is mandatory in some countries, and permitted in others. Infant formula and hquid milk are commonly fortified with vitamin D, and two studies have shown that fortification can be vastly in excess of what is stated on the label (65,66). In one case this was detected when hjrpervitaminosis D was found in the population. In one case hjrpercalcemia occurred after prolonged feeding with a premature formula that was higher than normal in vitamin D (67). 

Mandatory iodine fortification of table salt and salt in bread was initiated in 2000—2001 (Laurberg et ai, 2006), and the Danish National Survey of Dietary Habits and Physical Activity 2000—2002 (Lyhne et al., 2005) subsequently found the median iodine intake among 55—75-year-old subjects to be 153—187 p,g/day (Table... 

Surveillance of Thyroid Disorders and Iodine Intake in the Danish Population before and after Mandatory Iodide Fortification of Salt The DanThyr Program... 

A program of monitoring was mandatory. In addition to regular measurement of the iodine content of iodized salt and checking the market share of iodized salt in Denmark, monitoring should include investigations of iodine intake and the occurrence of thyroid diseases in areas of both mild and moderate ID before and after fortification. 

Figure 119.5 Incidence rates of overt hyperthyroidism before and after iodine fortification (IF) of salt. The incidence rate of hyperthyroidism in Aalborg (moderate ID) and Copenhagen (mild ID) before and after the first 6 years of IF of salt. Basic is the time before IF of salt (1997-1998), 1999-2000 is the period of voluntary IF, 2001-2002 is the early, and 2003-2004 is the late period of mandatory IF. The incidence of hyperthyroidism increased significantly in both subcohorts during the study period. In Aalborg, the increase was more pronounced and came before the increase in Copenhagen. Aalborg baseline vs. voluntary IF, P< 0.001 voluntary IF vs. early mandatory IF, P s 0.001 early vs. late mandatory IF, ns. Copenhagen baseline vs. voluntary IF, ns voluntary IF vs. early mandatory IF, P s 0.001 early vs. late mandatory IF, ns. Statistical significance compared with baseline, P < 0.05 P s 0.01 P s 0.001. Data from Pedersen et al., (2006).

Figure 119.6 Incidence rates of overt hypothyroidism before and after iodine fortification of salt. The incidence of hypothyroidism in Aalborg with previous moderate ID and Copenhagen with previous mild ID in three periods with different iodine intake compared to baseline, which is the preiodine incidence. The vertical bars indicate the 95% Cl to the rate. In Copenhagen the incidence of hypothyroidism was stable. In Aalborg, however, the incidence rates of hypothyroidism were significantly higher in both periods with mandatory ID compared to baseline, as one was not included in the 95% Cl. Data from Pedersen et al., (2007).

Mandatory iodine fortification to reach all subgroups, coupled with ongoing vigilance and monitoring is needed to ensure that iodine deficiency, a readily preventable but potentially devastating nutritional disorder, is efiminated in the Tasmanian population. 

Standards Code is not a simple process it requires the preparation of three assessment reports and two rounds of public consultation by Food Standard Australia New Zealand. The Australia and New Zealand Food Regulation Ministerial Council is then notified of the final report, which they can choose to adopt, amend, reject, or may request for a review. Now that the new food standard has been accepted, the regulation comes into effect after a set transition period (usually 12 months). Mandatory iodine fortification will be in place more than 10 years after the re-emergence of iodine deficiency in New Zealand was identified. 

Wright, A. J. A., Dainty, J. R., and Finglas, P. M. 2007. Folic acid metabolism in human subjects revisited Potential implications for proposed mandatory folic acid fortification in the UK. Br. J. Nutr. 98 667-675. 

Folate plays an important role in the development and function of the central nervous system. The high folate levels in cerebrospinal fluid give an indication of its importance. An insufficient folate status during the early weeks of gestation leads to problems with the development of the neural tube. Peri-conceptual folic acid reduces the rate of neural tube defects in the general population, and is the reason for the mandatory folic acid fortification of cereals in the US and Canada. 

Figueiredo et al. 2009). In addition, an analysis of secular trends of colorectal cancer incidence in the United States also prompted concerns by showing transient upward fluctuations in colorectal cancer after 1995 that were attributed to the introduction of mandatory folic acid fortification in February 1996 (although the fluctuations in colorectal cancer incidence could equally reflect improved screening introduced at the same time) (Mason et al. 2007). 

Kim, Y.I., 2004. Will mandatory folic acid fortification prevent or promote cancer The American Journal of Clinical Nutrition. 80 1123-1128. 

The introduction of 140 pg of folic acid per 100 g of flour in the USA, calculated to increase individual consumption of folic acid by 100 pgday , has reduced the incidence of abnormally low plasma folate from 21% to less than 2%, the incidence of mild hyperhomocysteinemia from 21% to 10%, and, most importantly, the incidence of NTD by about 20% over the first years of universal fortification. Because 30% of the population takes vitamin supplements and presumably would not be expected to derive significant benefit from fortification, the actual effect may be closer to a 30% decrease due to fortification. Recent calculations suggest that, for a variety of reasons, the overall fortification amount was about twice the mandatory amount. 

---