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The health consequences of this mutation in the adolescent and adult population are currently not known. When discussing the safety of vitamin D food fortification it must also be noted that improvement of vitamin D status by systematic food fortification may also likewise decrease the prevalence of persons taking vitamin D supplements exceeding the UL. In this context, it should also be noted that intermittent high dose vitamin D supplementation is quite common but may pose risk of adverse events.

While daily vitamin D supplements with doses according to the RDA or equivalents are safe, intermittent high dose vitamin D supplementation may even increase the risk of fractures and falls Even before vitamin D was discovered, it had been observed that cod liver oil protects against rickets. Successful treatment of rickets has also been demonstrated by sunlight or UV exposure of children in the s followed by documentation that irradiation of food such as milk increased its anti-rachitic activity.

Vitamin D food fortification has been widely introduced in the s and s in the United States and many other industrialized countries such Great Britain when it became possible to add purified vitamin D itself to food In particular vitamin D fortified milk was produced at that time, but vitamin D has also been added to a variety of foods and beverages including amongst others beer, hot dogs and custard. This food fortification policy was extremely effective in preventing rickets but in the s there was a change in public health policy as food fortification was banned in Great Britain and many other European countries because cases of hypercalcemia were observed that had been suspected to be attributable to vitamin D intoxication.

Whether this was really the case is not clear. Beyond the combined effect of vitamin D overdosing due to different sources [heavy vitamin D enrichment of dried milk powder plus vitamin D fortified cereals plus daily supplement with This syndrome is, apart from other pathologies, associated with hypercalcemia.

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Unfortunately, methods for measuring circulating 25 OH D were not available at that time. Some symptoms of hypercalcemia had, however, been observed in infants in the former German Democratic Republic, where infants were supplemented with intermittent doses of 15 mg , IU of vitamin D as an effort to prevent rickets 77 , Overviews of current food fortification policies have been reviewed elsewhere 62 , 73 , 74 , 99 — There is a huge variation in availability of vitamin D fortified food or food with vitamin D bioaddition across the countries.

In general, there are mandatory and voluntary vitamin D food fortification policies but their differentiation is not always trivial as there can be varying pressure and implementation success of voluntary vitamin D food fortification. Many other countries allow voluntary vitamin D food fortification but with only insufficient effects on vitamin D intakes at population level , Legislation is, of course, the basis for vitamin D food fortification and while we cannot discuss this issue in detail, we want to point out that the general regulation of voluntary food fortification is harmonized across the European Union , , Several countries, however, still refer to national laws restricting addition of vitamins and minerals to food.

In Germany, for example, addition of vitamin D to food is limited to margarine, based on a law of As the experience with systematic mass vitamin D food fortification in the US, Canada and Finland may provide important guidance for health authorities in other regions, we list the main vitamin D fortified foods currently practiced in these countries in Table 3 99 , , — , — In particular, the example of Finland can serve as a benchmark for future vitamin D food fortification policies in other countries. In Finland, vitamin D status has recently been assessed in nationally representative samples before and after introduction of systematic vitamin D food fortification In a nationally representative survey of Finnish adults, changes in serum 25 OH D concentrations from to were investigated Mean serum 25 OH D concentrations increased from Therefore, and to conclude, the Finnish vitamin D nutrition policy, based on appropriate simulations, has considerably improved vitamin D status in the general Finnish population.

Dangers of Food Fortification and Enrichment

This implementation of a systematic vitamin D food fortification programme respresents an example of a successful public health action that may inform similar approaches in other countries. Importantly, vitamin D food fortification policies have been re-evaluated and modified if necessary , Apart from Western countries, there are also efforts for vitamin D food fortification in countries such as India with e. Identifying the need for systematic vitamin D food fortification requires, of course, the assessment of 25 OH D status and vitamin D intakes in a respective country or population in order to show that the dietary vitamin D requirements are not met.

These data, which should at best be derived from a nationally representative sample of the population, can then serve as the basis for modeling vitamin D food fortification scenarios to meet the vitamin D requirements — A particular focus on groups at highest risk of profound vitamin D deficiency e. In a very simplified view there are three different approaches for modeling effects of vitamin D food fortification scenarios.

First, based on vitamin D intakes and nutrition habits in the population it can be estimated how vitamin D fortification affects nutritional vitamin D intakes by simply adding existing and additional vitamin D intakes by food fortification Second, based on the previous approach and the availability of 25 OH D concentrations and by use of a dose-response equation of vitamin D intake and 25 OH D serum concentrations, it can be estimated how vitamin D fortification affects not only dietary vitamin D intakes but also serum 25 OH D concentrations Third, in addition to the second approach the additional impact of UV exposure with its seasonal variation is considered to model the effect of vitamin D food fortification on 25 OH D serum concentrations , , All of these models have their limitations in particular due to some underlying assumptions so that cautious interpretation of the results is warranted.

Simple modeling of an equation on the vitamin D intake-serum 25 OH D relationship does, however, not reflect potentially modifying factors such as body mass index, age, basal serum 25 OH D concentrations or genetics When considering introduction of systematic vitamin D food fortification, a key question relates to whether or not such a public health intervention is likely to be cost-effective — In general, micronutrient fortification is considered as being one of the most cost-effective public health interventions With reference to vitamin D food fortification there is, however, only limited evidence available on its cost-effectiveness.

Nevertheless, the available studies on this issue point toward the notion that systematic vitamin D fortification or vitamin D supplementation may indeed be highly cost-effective — Regarding the costs for a typical food fortification programme, Fiedler et al. This would translate into a benefit-cost ratio of which is even more conservative than other estimates of the cost-effectiveness of pure vitamin D interventions with even higher benefit-cost ratios , — We are well aware that more data are needed on the cost-effectiveness of systematic vitamin D fortification but we conclude that, despite limited evidence, the available literature suggests that this approach is highly likely to be cost-effective.

Despite these promising data, it must be stressed that the overall general health impact of systematic vitamin D food fortification or supplementation can only roughly be estimated — It should also be mentioned that most studies assessed the cost-effectiveness of vitamin D food fortification in the elderly population and not in the whole population.

Beyond cost effectiveness it is, however of course, extremely important that such fortification approaches are also well perceived and accepted by the population itself.

Fortification of foods:

This seems to be the case for vitamin D as e. The Finnish data also suggest that vitamin D food fortification is well accepted and fortified foods are considered part of the habitual diet There is definitely no clear answer on how to implement systematic vitamin D food fortification in countries where the vitamin D dietary requirements are not met by a significant part of the general population.

Nevertheless, we want to provide some guidance for this task see Figure 2.

A first step is, of course, the evaluation of the vitamin D status and intakes from nationally representative nutrition and health surveys. Definition of a precise goal for vitamin D food fortification is not a trivial task, but the general aim is, of course, to improve vitamin D status while avoiding or minimizing risk of potential toxicity related to overdosing of vitamin D.


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Although not clearly outlined in the WHO guideline it appears reasonable to argue that intakes below this goal are a reason for public health actions. Being aware of the heterogeneity of nutritional vitamin D guidelines we are convinced that if significantly more than 2. The WHO guideline on food fortification suggests the target is to shift the intake distribution upwards so that only 2.

This would, for a hypothetical usual intake distribution, result in a target median intake about 1. This provides extremely strong arguments for the safety of vitamin D because the Finish data indicate that with vitamin D food fortification there is a much higher increase in 25 OH D in those with very low 25 OH D concentrations at baseline when compared to those with high 25 OH D concentrations at baseline.

In general, we see two broad approaches to implementation of systematic vitamin D food fortification. The first one adheres to previous systematic vitamin D food fortifications in countries with similar population characteristics in terms of vitamin D status and food habits that have been evaluated with regard to safety and efficacy, as it has been done in Finland.

It is a reasonable approach to follow the example of the Finnish vitamin D food fortification policy when modeling of the effects of such a vitamin D food fortification results in a significant and safe improvement of vitamin D status and intakes. It is clear from hypothetical models of vitamin D intakes and status that fortifying multiple food staples is desirable because such approaches reach broader parts of the population and are theoretically more safe than just fortifying one or a few food staples.

However, such approaches are more costly and will likewise have a lower acceptance as there are currently no countries using and evaluating such approaches. As some of the authors reside in Austria and Germany we wish to briefly outline the conceivable food fortification scenarios in these two countries — Data from national representative samples on vitamin D status and intakes in Austria and Germany are shown in Table 4. It is obvious from the high prevalence of low 25 OH D concentrations and the low dietary vitamin D intakes that vitamin D food fortification is necessary in these countries to meet the vitamin D requirements.

In this context, we wish to underline that there is long experience with vitamin D food fortification of dairy products in different countries covering a wide range of different nutritional habits, lifestyle and latitudes. Modeling of such a vitamin D fortification scenario on vitamin D intakes and on serum 25 OH D concentrations is, of course, definitely required. Importantly, in Austria and Germany there is a similar yet slightly lower dairy intake but slightly higher 25 OH D concentrations compared to Finland before the introduction of systematic vitamin D food fortification, suggesting that the Finnish approach may be a good model for these two countries Standardized measurements of 25 OH D status and assessment of overall vitamin D intakes in nationally representative samples before and after implementation of vitamin D food fortification should be, of course, a condition sine qua non.

While we hope for and work on the improvement of food fortification approaches in the future, it is now time to take action and work on the improvement of vitamin D status in countries where significant parts of the population fail to meet the dietary requirements. For this aim, the best evaluated vitamin D food fortification strategies with the likewise highest rates of successful implementation should be pursued. In this review, we outlined the background, rationale and current status of systematic vitamin D food fortification and also gave some guidance for implementation of such an approach see Table 5 for key points.

We are of the opinion that the huge gap between the nutritional vitamin D guideline recommendations and the high prevalence of individuals who do not meet their vitamin D requirements calls for public health actions that can be performed by systematic vitamin D food fortification.

While there are still many questions surrounding this issue, several countries do have long experience with systematic vitamin D food fortification — The successful and well evaluated real-life experience with the Finnish food fortification policy may be used as a benchmark for other countries with similar population characteristics.

We do hope that our work helps to introduce and modify vitamin D food fortification in those countries where it is needed in order to prevent the significant public health burden of vitamin D deficiency and its adverse consequences. All authors contributed to manuscript revision, read and approved the submitted version. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Vitamin D in preventive medicine. Anticancer Res.

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Proc Nutr Soc. Bouillon R. Comparative analysis of nutritional guidelines for vitamin D. Nat Rev Endocrinol. Vitamin D: current guidelines and future outlook. Cashman KD. Vitamin D: dietary requirements and food fortification as a means of helping achieve adequate vitamin D status. J Steroid Biochem Mol Biol. Food fortification as a means to increase vitamin D intake. Br J Nutr. Vitamin D: metabolism, molecular mechanism of action, and pleiotropic effects. Physiol Rev. Trends in use of high-dose Vitamin D supplements exceeding or International units daily, JAMA — Vitamin D stored in fat tissue during a 5-year intervention affects serum hydroxyvitamin D Levels the following year.

J Clin Endocrinol Metab. Sunlight and dietary contributions to the seasonal vitamin D status of cohorts of healthy postmenopausal women living at northerly latitudes: a major cause for concern? Osteoporos Int. Genome-wide association study in 79, European-ancestry individuals informs the genetic architecture of hydroxyvitamin D levels. Nat Commun. Genetic and Racial Differences in the Vitamin D endocrine system. Endocrinol Metab Clin North Am. Current Controversies: are free vitamin metabolite levels a more accurate assessment of Vitamin D status than total levels?

Hormonal contraceptive use is associated with higher total but unaltered free hydroxyvitamin D serum concentrations. Jorde R, Grimnes G. Serum cholecalciferol may be a better marker of vitamin D status than hydroxyvitamin D. Med Hypotheses —5. Nat Rev Dis Primers Nutritional rickets and Osteomalacia in the Twenty-first Century: revised concepts, public health, and prevention strategies. Curr Osteoporos Rep.

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