European Journal of Clinical Nutrition (2011) 65, 313320

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ORIGINAL ARTICLE

Discretionary addition of vitamins and minerals to foods: implications for healthy eating
JE Sacco and V Tarasuk
Faculty of Medicine, Department of Nutritional Sciences, University of Toronto, Toronto, ON, Canada

Objectives: Health Canada proposes to allow manufacturers to add vitamins and minerals to a wide variety of foods at their discretion, a practice that has long been permitted in the United States and Europe. With Health Canadas proposed exclusion of staple and standardized foods from discretionary fortification, questions arise about the nutritional quality of the foods that remain eligible for fortification. To better understand the implications of this policy for healthy eating, this study examined the contribution of foods eligible to be fortified to the dietary quality of Canadians. Methods: Using 24-h dietary recall data from the 2004 Canadian Community Health Survey, the relationship between intake of fortifiable foods and indicators of dietary quality was assessed. Results: The mean percentage contribution of fortifiable foods to usual energy intake ranged from 19% among men over the age of 70 years to 36% for girls aged 1418 years. Fortifiable food (as a percentage of total energy) was inversely associated with intake of vegetables and fruit, meat and alternatives, milk products, fiber, vitamins A, B6, B12 and D, magnesium, potassium and zinc. Fortifiable food was positively associated with dietary energy density, total energy intake and grain products. Few relationships were found for folate, vitamin C, iron, calcium, sodium and saturated fat. Conclusions: Consumption of foods slated for discretionary fortification is associated with lower nutrient intakes and suboptimal food intake patterns. Insofar as adding nutrients to these foods reinforces their consumption, discretionary fortification might function to discourage healthier eating patterns.

European Journal of Clinical Nutrition (2011) 65, 313320; doi:10.1038/ejcn.2010.261; published online 1 December 2010
Keywords: food fortification; dietary quality; vitamins; minerals

Introduction
Discretionary fortification, the addition of vitamins and minerals to foods at the discretion of manufacturers, has long been permitted in the United States (Food and Drug Administration, 1993) and in parts of Europe (Sichert-Hellert et al., 2000; Hannon et al., 2007), and in 2007, harmonized regulations came into effect in the European Union (European Parliament, 2006). A review of the Codex Alimentarius general principles for the addition of vitamins and minerals to foods has also been initiated, in part to discuss the introduction of international standards for the practice of discretionary fortification (Codex Alimentarius Commission, 2007). The population health implications of

Correspondence: Dr V Tarasuk, Faculty of Medicine, Department of Nutritional Sciences, University of Toronto, FitzGerald Building, Room 326, 150 College Street, Toronto, ON M5S 3E2, Canada. E-mail: valerie.tarasuk@utoronto.ca Received 18 August 2010; revised 27 October 2010; accepted 28 October 2010; published online 1 December 2010

this practice have been the subject of little research, but studies have indicated that discretionarily fortified foods contribute significantly to overall nutrient intake and apparent nutrient adequacy (Subar and Bowering, 1988; Sichert-Hellert et al., 2000, 2001; Berner et al., 2001; Wagner et al., 2005; Hannon et al., 2007). The effect of discretionary fortification on food selection and dietary patterns has not been examined, but as concerns about the growing prevalence of obesity mount, manufacturers use of nutrient additions to market foods of otherwise low nutritional value is coming into question (Nestle and Ludwig, 2010). Although widespread discretionary fortification is not currently permitted in Canada, a policy was proposed by (Health Canada, 2005) and stakeholder consultations seem to be ongoing (Yan, 2010). In the interim, components of the proposed discretionary fortification policy are being used to evaluate products for approval as Natural Health Products, resulting in a recent increase in the availability of foods with added vitamins and minerals in Canada (Natural Health Products Directorate, Health Canada, 2006; Natural Health Products Directorate and Food Directorate, 2009).

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Similar to the assessments of discretionary fortification policies in other jurisdictions (Coppens et al., 2006), Health Canada conducted preliminary risk assessment modeling in developing their proposed policy (Health Canada, 2005). This assessment focused exclusively on safety considerations associated with the potential for excess nutrient exposures. The resultant policy proposal restricts the selection and levels of nutrients that can be added; permitted nutrients include vitamins E, D, C, B6 and B12, b-carotene, thiamin, niacin, riboflavin, biotin, pantothenate, folate, calcium, magnesium and potassium. The policy proposal also excludes certain staple and standardized foods (such as those with a standard of identity in the FDR (Food and Drug Regulations)) from fortification (Supplementary Table 1). These are widely consumed foods that, if fortified voluntarily, could pose risks of excessive nutrient intake. However, foods left after these exclusions include many snack foods (popularly termed junk foods), leading some to argue that discretionary fortification will promote an obesogenic diet (Beauchesne and Kondro, 2009). Such concerns arise because of the presumed marketing potential associated with the nutritional enhancement of foods (Moorman, 1998). However, there has been little research into the effects of discretionary fortification on dietary behaviors. To gain an understanding of the potential population health implications of introducing a discretionary fortification policy that could function to promote the consumption of particular foods, we undertook an examination of the contribution of fortifiable foods to the dietary quality of Canadian adults and children currently. of identity in the FDR because a regulatory amendment to the FDR would be required to permit fortification of these foods. All remaining foods in the CCHS database were considered to be eligible for fortification (Supplementary Table 2). Eligible foods comprise 32% of food codes in the database. Fortifiable foods were grouped into nine classes based on categories used in the Canadian Nutrient File (Supplementary Table 2). To determine the most commonly consumed fortifiable foods, the mean proportion of energy intakes obtained from each class of fortifiable foods was estimated. Survey weights were applied to these analyses, incorporating the bootstrapping method of variance estimation, which takes into account unequal probability of selection and the stratification and clustering in the CCHS 2.2 survey design (Statistics Canada, 2008). To characterize the habitual levels of consumption of fortifiable foods among Canadians, the proportion of individuals usual energy intakes obtained from fortifiable foods was assessed. As food intake varies dramatically from one day to the next, we used Software for Intake Distribution Estimation (SIDE) (SIDE-IML version 1.11, 2001, Iowa State University, Ames, IA, USA) to estimate the usual proportion of energy intake from fortifiable foods, applying survey weights (Statistics Canada, 2008). SIDE uses both 24-h dietary recalls to estimate and attenuate the effect of random within-individual variation, and to estimate the usual proportion of energy intakes from fortifiable foods. Linear regressions were conducted to examine the association between fortifiable food consumption and dietary quality, using each indicator of dietary quality as the dependent variable, and the proportion of energy from fortifiable foods as a single predictor. Indicators of dietary quality included total energy intake, servings from each of the four food groups (as defined in Canadas Food Guide (Health Canada, 2007a)), and intake of nutrients for which there are concerns of inadequate, suboptimal or excessive intake in Canada, based on the assessment of nutrient adequacy in CCHS 2.2 (Health Canada 2007b; Health Canada, 2008a). These nutrients are saturated fat, fiber, sodium, magnesium, iron, zinc, potassium, vitamins A, B6, D, C and B12, calcium and folate. Examination of residual plots revealed non-normally distributed residuals for some nutrients; therefore, vitamins A, B12, C and D, iron and zinc were (natural) log transformed in the regression models presented in this study, to better approximate normality. Dietary energy density was also included as an indicator of dietary quality, as it has been implicated in the development of obesity (Ledikwe et al., 2005). Energy density was calculated for each respondent by dividing the total energy intake in kilojoules by the total amount of food consumed in grams, excluding non-nutritive beverages because they can disproportionately influence energy density values (Ledikwe et al., 2005). All analyses were conducted using SAS (version 9.2 (2008), SAS Institute, Cary, NC, USA). Analyses were conducted separately for 14 age and sex groups. Significance was

Materials and methods

Ethics approval for this study was obtained from the University of Toronto Research Ethics Board. Dietary intake data from the Canadian Community Health Survey, Cycle 2.2 (CCHS 2.2) were used. The CCHS 2.2 collected dietary intake data from 35 107 Canadians in 2004 (Health Canada, Office of Nutrition Policy and Promotion, Health Products and Food Branch, 2006) using an interviewer-administered, multiple pass, 24-h recall (Statistics Canada, 2008). A second 24-h recall was collected from approximately one-third of the sample. The CCHS 2.2 sampled individuals from each of the 10 provinces, excluding members of the Canadian Forces, individuals living on First Nations Reserves, Crown Lands, in prisons or care facilities or those living in some remote areas. The sample used for this analysis (n 34 383) also excluded respondents with zero energy intakes, pregnant and lactating women, children o1 year of age and those who only consumed breast milk. The nutrient composition of foods found in the database is derived primarily from the Canadian Nutrient File (supplemented 2001b version) (Statistics Canada, 2008). For this analysis, foods explicitly excluded by Health Canada (Supplementary Table 1) were considered ineligible for discretionary fortification, as were foods with a standard European Journal of Clinical Nutrition

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determined using the Bonferroni adjustment for multiple comparisons (Po0.0002). potassium (Tables 4 and 5). Few significant associations were found for folate, calcium, vitamin C, iron, saturated fat or sodium (Tables 4 and 5).

Results
Almost every respondents 24-h dietary recall (95%) included at least one fortifiable food. The mean usual percentage contribution of fortifiable foods to usual energy intake among Canadians appeared to be highest among younger age groups, ranging from 19% among men over the age of 70 years to 36% for girls aged 1418 years (Table 1). Particularly among younger age groups, fortifiable foods comprised upwards of 50% of usual energy intake for many individuals (Figure 1). The fortifiable foods that contributed the most to energy intakes were baked goods and beverages, and this was consistent across all age/sex groups (Table 2). For most age and sex groups, there was a significant inverse relationship between the percentage of energy from fortifiable foods and the number of servings of fruit and vegetables, milk products, as well as meat and alternatives (Table 3). Applying the b-values in Table 3 to current intakes to further illustrate the magnitude of the associations, we found that the decrease in fruit and vegetable intake estimated to result from a shift from the 25th to the 75th percentile of fortifiable food intake ranges from 0.1 servings for men aged 470 years of age to 0.6 servings for men aged 1930 years of age. Significant positive relationships were found for grain products, dietary energy density and total energy intake, among almost all age and sex groups (Table 3). Significant inverse associations were found for intakes of vitamins A, D, B6 and B12, magnesium, zinc, fiber and

Discussion
Canadians derive a substantial proportion of their energy intakes from foods that are eligible to be fortified under Health Canadas proposed discretionary fortification policy. The higher their intakes of these foods, the lower their intakes of fruit and vegetables, milk products, meat and alternatives, as well as many vitamins and minerals of concern. These results suggest that fortifiable foods exert a
6 5 Probability Density median (boys) = 34% 4 3 2 1 0 0 10 20 30 40 50 60 70 Percentage of Usual Energy from Fortifiable Foods
Figure 1 Distribution of usual energy intake from fortifiable foods for boys and girls aged 1418 years.

median (girls) = 36% Boys Girls

Table 1 Proportion of usual energy intakes from fortifiable foods in the Canadian population by age and sex groupa Age (years)/sex N Mean s.d. 5th 10th 25th %/d Males/females 13 48 Males 913 1418 1930 3150 5170 X71 Females 913 1418 1930 3150 5170 X71
a

Percentiles 50th 75th 90th 95th

2193 3343

23 33

9 7

9 21

12 23

16 27

22 32

29 38

36 42

40 45

2149 2397 1897 2748 2725 1601

35 35 28 25 20 19

8 10 9 13 9 8

21 19 15 6 8 8

24 22 17 9 10 10

29 28 22 15 14 14

34 34 28 23 19 19

40 42 34 33 26 24

46 49 39 42 32 29

49 53 43 48 36 33

2043 2346 1914 2851 3407 2769

35 36 31 26 22 21

8 8 8 9 9 7

22 23 18 13 9 10

25 26 20 16 11 12

29 30 25 20 15 16

35 36 30 26 21 21

41 41 36 32 27 26

46 46 42 38 34 31

50 49 45 42 38 34

Based on analysis of data adjusted for day-to-day variability in nutrient intakes using Software for Intake Distribution Estimation (SIDE).

European Journal of Clinical Nutrition

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Table 2 Proportion of energy intakes from fortifiable foods by food category and DRI groupa,b Age (years)/sex N All foods Dairy products Mean (s.e.) % Soups, sauces and gravies Mean (s.e.) % Fruit and vegetable products Mean (s.e.) % Beverages Nut, seed and legume products Mean (s.e.) % Baked goods Mean (s.e.) % Sweets Mixed dishes Mean (s.e.) % Snacks

Mean (s.e.) % Males/females 13 48 Males 913 1418 1930 3150 5170 X71 Females 913 1418 1930 3150 5170 X71
a

Mean (s.e.) %

Mean (s.e.) %

Mean (s.e.) %

2193 3343

23 (1) 32 (0)

2 (0) 2 (0)

1 (0) 1 (0)

2 (0) 2 (0)

3 (0) 6 (0)

1 (0) 1 (0)

7 (0) 10 (0)

3 (0) 3 (0)

2 (0) 4 (0)

2 (0) 4 (0)

2149 2397 1897 2748 2725 1601

34 35 29 23 20 19

(1) (1) (1) (1) (0) (1)

1 1 1 1 1 1

(0) (0) (0) (0) (0) (0)

2 2 2 3 2 3

(0) (0) (0) (0) (0) (0)

2 2 2 2 1 1

(0) (0) (0) (0) (0) (0)

7 9 7 5 3 2

(0) (0) (0) (0) (0) (0)

1 1 1 1 1 1

(0) (0) (0) (0) (0) (0)

9 7 6 6 7 9

(0) (0) (0) (0) (0) (1)

4 3 2 1 1 1

(0) (0) (0) (0) (0) (0)

4 5 4 3 2 1

(0) (0) (0) (0) (0) (0)

4 5 3 2 2 0

(0) (0) (0) (0) (0) (0)

2043 2346 1914 2851 3407 2769

35 35 30 25 22 21

(1) (1) (1) (1) (1) (0)

1 1 1 1 2 1

(0) (0) (0) (0) (0) (0)

2 3 2 2 2 2

(0) (0) (0) (0) (0) (0)

2 3 2 2 1 1

(0) (0) (0) (0) (0) (0)

7 8 7 4 3 2

(0) (0) (0) (0) (0) (0)

1 1 1 1 1 1

(0) (0) (0) (0) (0) (0)

9 8 6 7 8 10

(0) (0) (0) (0) (0) (0)

3 4 2 2 2 2

(0) (0) (0) (0) (0) (0)

4 4 4 3 2 1

(0) (0) (0) (0) (0) (0)

5 4 4 3 1 1

(0) (0) (0) (0) (0) (0)

See Supplementary Table 2 for details on the specific foods included within each category. Estimates incorporate survey weights and have been bootstrapped, taking into account the complex survey design.

Table 3 Regression coefficients for association between number of servings of each food group and percentage of energy from fortified foods Age (years)/sex N Grain products Fruits and vegetables Milk products Meat and alternatives Energy density (kJ/g) Energy (kJ)

b (s.e.) Males/females 13 48 Males 913 1418 1930 3150 5170 X71 Females 913 1418 1930 3150 5170 X71

2193 3343

0.03 (0.00)* 0.01 (0.00)*

0.02 (0.00)* 0.04 (0.00)*

0.02 (0.00)* 0.01 (0.00)*

0.01 (0.00)* 0.03 (0.00)*

0.03 (0.00)* 0.04 (0.00)*

5.43 (0.71)* 3.37 (0.63)*

2149 2397 1897 2748 2725 1601

0.01 0.00 0.01 0.03 0.03 0.04

(0.00) (0.01) (0.01) (0.00)* (0.00)* (0.01)*

0.03 0.04 0.05 0.03 0.02 0.01

(0.00)* (0.00)* (0.00)* (0.00)* (0.00)* (0.01)

0.02 0.02 0.01 0.00 0.00 0.00

(0.00)* (0.00)* (0.00) (0.00) (0.00) (0.00)

0.04 0.05 0.06 0.05 0.04 0.04

(0.00)* (0.00)* (0.00)* (0.00)* (0.00)* (0.01)*

0.04 0.05 0.05 0.04 0.03 0.02

(0.00)* (0.00)* (0.00)* (0.00)* (0.00)* (0.00)*

4.62 1.76 0.01 5.35 6.06 6.03

(1.08)* (1.33) (1.45) (1.15)* (1.08)* (1.23)*

2043 2346 1914 2851 3407 2769

0.02 0.01 0.01 0.01 0.02 0.03

(0.00)* (0.00) (0.00) (0.00)* (0.00)* (0.00)*

0.04 0.04 0.04 0.03 0.02 0.02

(0.00)* (0.00)* (0.00)* (0.00)* (0.00)* (0.00)*

0.01 0.01 0.01 0.00 0.00 0.00

(0.00)* (0.00)* (0.00)* (0.00) (0.00) (0.00)

0.03 0.03 0.03 0.03 0.03 0.02

(0.00)* (0.00)* (0.00)* (0.00)* (0.00)* (0.00)*

0.05 0.05 0.04 0.04 0.03 0.03

(0.00)* (0.00)* (0.00)* (0.00)* (0.00)* (0.00)*

4.57 3.11 2.19 3.54 5.46 5.25

(0.88)* (0.88) (0.92) (0.80)* (0.68)* (0.69)*

*Significant at Po0.0002.

negative influence on the nutritional quality of individuals intakes overall. Although intakes of most micronutrients are inversely associated with fortifiable food intake, there were some notable exceptions. The absence of significant associations between fortifiable food intake and both vitamin C and folate for many age/sex groups may reflect the impact of European Journal of Clinical Nutrition

existing fortification programs. In Canada, fortification of white flour and pasta with folic acid is mandatory, contributing large amounts of folic acid to both fortifiable and non-fortifiable foods (Health Canada, 2008b). Similarly, the absence of significant findings for vitamin C may reflect widespread consumption of vitamin C-fortified fruit-flavored drinks, which are permitted under existing fortification

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Table 4 Regression coefficients for association between nutrient intakes and percentage of energy from fortified foods Age (years)/sex N Calcium (mg) Magnesium (mg) Potassium (mg) Iron (mg)a b (s.e.) Males/females 13 2193 6.17 (0.71)a 48 3343 3.67 (0.51)* Males 913 1418 1930 3150 5170 X71 Females 913 1418 1930 3150 5170 X71 Zinc (mg)a Sodium (mg) Saturated fat (g) Fiber (g)

0.42 (0.12) 0.83 (0.10)*

7.66 (1.29)* 0.002 (0.00) 0.003 (0.00)* 10.86 (1.01)* 0.001 (0.00) 0.005 (0.00)*

7.13 (1.44)* 0.02 (0.02) 0.02 (0.01) 1.23 (1.25) 0.05 (0.01)* 0.02 (0.01)*

2149 4.17 (0.79)* 2397 4.90 (0.89)* 1897 2.88 (0.91) 2748 0.02 (0.69) 2725 0.26 (0.63) 1601 0.15 (0.81)

1.03 1.77 1.96 1.04 0.73 0.46

(0.16)* (0.19)* (0.23)* (0.19)* (0.19)* (0.25)

12.52 19.11 21.02 9.98 8.01 6.24

(1.62)* (1.88)* (2.12)* (1.79)* (1.74)* (2.29)

0.002 0.004 0.004 0.001 0.000 0.002

(0.00) (0.00)* (0.00)* (0.00) (0.00) (0.00)

0.005 0.007 0.008 0.005 0.003 0.003

(0.00)* 0.62 (2.08) 0.02 (0.02) (0.00)* 5.82 (2.37) 0.06 (0.02) (0.00)* 5.37 (2.62) 0.07 (0.02) (0.00)* 4.90 (2.15) 0.05 (0.02) (0.00)* 8.53 (2.17)* 0.06 (0.02) (0.00) 7.40 (3.12) 0.05 (0.02)

0.02 0.06 0.06 0.03 0.01 0.03

(0.01) (0.01)* (0.01)* (0.01) (0.01) (0.02)

2043 2346 1914 2851 3407 2769

3.16 3.85 2.13 0.68 0.08 0.71

(0.67)* (0.61)* (0.65) (0.54) (0.48) (0.52)

0.99 1.12 1.13 1.09 0.60 0.48

(0.13)* (0.13)* (0.15)* (0.15)* (0.14)* (0.15)

11.91 12.72 10.88 11.58 6.32 6.72

(1.36)* (1.31)* (1.44)* (1.31)* (1.26)* (1.32)*

0.000 0.002 0.002 0.001 0.000 0.001

(0.00) (0.00) (0.00)* (0.00) (0.00) (0.00)

0.004 0.006 0.005 0.004 0.003 0.003

(0.00)* 3.20 (1.71) 0.01 (0.02) (0.00)* 0.76 (1.59) 0.02 (0.02) (0.00)* 2.80 (1.70) 0.00 (0.02) (0.00)* 3.08 (1.59) 0.03 (0.01) (0.00)* 5.52 (1.39)* 0.05 (0.01)* (0.00)* 7.87 (1.41)* 0.02 (0.01)

0.03 0.03 0.04 0.04 0.03 0.01

(0.01)* (0.01)* (0.01)* (0.01)* (0.01) (0.01)

*Significant at Po0.0002. a Iron and zinc have been log transformed.

Table 5 Regression coefficients for association between nutrient intakes and percentage of energy from fortified foods Age (years)/sex N Folate (mg DFE) Vitamin A (mg RAE)a Vitamin C (mg)a b (s.e.) Males/females 13 48 Males 913 1418 1930 3150 5170 X71 Females 913 1418 1930 3150 5170 X71 Vitamin B6 (mg) Vitamin B12 (mcg)a Vitamin D (mcg)a

2193 3343

1.37 (0.23)* 0.19 (0.19)

0.00 (0.00) 0.01 (0.00)*

0.000 (0.00) 0.004 (0.00)*

0.00 (0.00)* 0.01 (0.00)*

0.01 (0.00)* 0.01 (0.00)*

0.009 (0.00)* 0.010 (0.00)*

2149 2397 1897 2748 2725 1601

0.04 0.50 0.98 0.37 0.90 1.09

(0.29) (0.34) (0.40) (0.31) (0.30) (0.36)

0.01 0.01 0.01 0.01 0.00 0.00

(0.00)* (0.00)* (0.00)* (0.00)* (0.00) (0.00)

0.001 0.006 0.007 0.001 0.000 0.001

(0.00) (0.00)* (0.00)* (0.00) (0.00) (0.00)

0.01 0.02 0.02 0.02 0.01 0.01

(0.00)* (0.00)* (0.00)* (0.00)* (0.00)* (0.00)*

0.01 0.01 0.01 0.01 0.01 0.01

(0.00)* (0.00)* (0.00)* (0.00)* (0.00)* (0.00)*

0.012 0.015 0.015 0.008 0.007 0.003

(0.00)* (0.00)* (0.00)* (0.00)* (0.00)* (0.00)

2043 2346 1914 2851 3407 2769

0.20 0.55 0.15 0.02 0.34 0.56

(0.25) (0.24) (0.26) (0.22) (0.21) (0.22)

0.01 0.01 0.01 0.01 0.01 0.00

(0.00)* (0.00)* (0.00)* (0.00)* (0.00)* (0.00)

0.003 0.002 0.007 0.006 0.003 0.003

(0.00) (0.00) (0.00)* (0.00)* (0.00) (0.00)

0.01 0.01 0.01 0.01 0.01 0.01

(0.00)* (0.00)* (0.00)* (0.00)* (0.00)* (0.00)*

0.01 0.01 0.01 0.01 0.01 0.01

(0.00)* (0.00)* (0.00)* (0.00)* (0.00)* (0.00)*

0.010 0.012 0.012 0.008 0.005 0.004

(0.00)* (0.00)* (0.00)* (0.00)* (0.00)* (0.00)*

Abbreviations: DFE, dietary folate equivalent; RAE, retinol activity equivalent. *Significant at Po0.0002. a Vitamins A, D, C and B12 have been log transformed.

regulations (Health Canada, 2008b). With the introduction of discretionary fortification, the observed inverse associations between fortifiable foods and micronutrient intakes can be expected to diminish for those nutrients slated for addition under the proposed policy. Two markers of poor dietary quality are saturated fat and sodium. We found few significant associations between

fortifiable food intake and sodium, reflecting the ubiquity of sodium in Canadians diets (Garriguet, 2007a). We also found few significant associations for saturated fat. This probably reflects the fact that, although some dietary saturated fat is derived from the fortifiable foods, two major sources of this nutrient, meat and dairy products, have been excluded from fortification. European Journal of Clinical Nutrition

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A more sensitive indicator of the adverse effect of fortifiable foods on dietary quality is energy density. Energy-dense diets have been found to reflect diets low in fruit and vegetables, and high in saturated fat, trans fat and refined carbohydrates (Kant and Graubard, 2005; Ledikwe et al., 2006; Bes-Rastrollo et al., 2008; Savage et al., 2008). Dietary energy density has also been associated with higher energy intake, weight gain and obesity in a number of crosssectional and prospective studies (Kant and Graubard, 2005; Ledikwe et al., 2006; Mendoza et al., 2007; Bes-Rastrollo et al., 2008; Savage et al., 2008). Although 24-h recall data limit our ability to draw inferences regarding individuals habitual dietary patterns, those who consumed diets high in fortifiable foods had a higher dietary energy density (and higher total energy intake), lending support to concerns that promoting the consumption of fortifiable foods may contribute to obesity (Beauchesne and Kondro, 2009). A limitation of this work is our inability to anticipate which foods are likely to be fortified, and which consumers will select these foods after implementation of discretionary fortification. We therefore examined fortifiable food consumption (as opposed to fortified food consumption). The relationships we observed between fortifiable food intake and dietary quality may be more or less pronounced when discretionary fortification is implemented, depending on consumer and manufacturer responses to discretionary fortification, and whether the nutrient is permitted for addition. Examinations of the contribution of fortified foods to overall dietary quality in jurisdictions where discretionary fortification is currently practiced have largely focused on breakfast cereals. These studies suggest that breakfast cereal consumption is associated with better dietary quality (Nicklas et al., 1995; Barton et al., 2005; Song et al., 2006; Joyce et al., 2009), particularly as it relates to increased milk consumption (Nicklas et al., 1995; Barton et al., 2005; Song et al., 2006), but leave open the question of the contribution of other fortified foods to overall dietary quality. Breakfast cereals were not considered in our analysis because they are subject to specific fortification regulations in Canada and do not fall under the proposed discretionary fortification policy (Health Canada, 2005; Department of Justice Canada, 2010). Although we are unable to determine whether fortifiable foods are displacing more healthful foods from the diets of Canadians, the observed inverse association between the consumption of fortifiable foods and milk products among children and adolescents raises the possibility that fortifiable beverages are displacing fluid milk. Further analyses (not shown) confirmed that the intake of fortifiable beverages was inversely associated with milk consumption among 913 year-old girls, but this association did not achieve statistical significance for boys or for older youth. Our findings are nonetheless concerning, insofar as discretionary fortification reinforces this beverage selection. Our earlier work modeling the impact of various implementation scenarios on the prevalence of nutrient inadeEuropean Journal of Clinical Nutrition quacies and excessive intakes in the Canadian population suggests that, if fully implemented, Health Canadas proposed discretionary fortification policy may not only reduce existing prevalences of nutrient inadequacy in Canada but it also has the potential to increase the risk of excessive nutrient intakes (Sacco and Tarasuk, 2009). This was particularly true for children and adolescents, who tended to experience larger shifts in their distribution of usual nutrient intakes. This finding can be explained by our current analysis, which indicates that younger individuals typically derive a greater proportion of their energy intakes from fortifiable foods. Many of the foods that are identified as foods to limit in Canadas Food Guide are eligible to be fortified. For example, Canadas Food Guide advises Canadians to limit their intake of foods and beverages high in calories, fat, sugar or sodium, and provides a list of examples of such foods (Health Canada, 2007a). This list includes cakes and pastries, cookies, granola bars, chocolate and candies, ice cream and frozen desserts, doughnuts and muffins, French fries, potato chips, nachos and other salty snacks, alcohol, fruit-flavored drinks, soft drinks, sports and energy drinks and sweetened hot or cold drinks. With the exception of alcohol, and a few foods with standards of identity (such as ice cream), the majority of these foods are eligible to be fortified. Therefore, Health Canadas proposed discretionary fortification policy is at odds with national dietary recommendations. The apparent contradiction between the kinds of foods slated for nutrient additions under the proposed discretionary fortification policy and those recommended in Canadas Food Guide is not surprising, given the very different goals underpinning these two initiatives. Although the food guide is meant to provide Canadians with guidelines for a food intake pattern that will meet nutrient requirements and minimize the risk of chronic disease (Health Canada, 2007a), the discretionary fortification policy was not intended, or expected, to improve Canadians micronutrient intakes (Health Canada, 2005). Concerns about the nutritional quality of foods eligible for discretionary fortification were raised in the early stages of policy development, prompting consideration of the exclusion of foods with components that may increase risks to health (for example, foods high in sodium, saturated or trans fat) or foods that do not contribute substantially to micronutrient intake (Health Canada, 2003). However, Health Canada concluded that applying these exclusion criteria would greatly limit the variety of foods eligible for fortification, which would ultimately restrict trade and innovation, and thus these exclusion criteria were not retained in the final policy proposal (Health Canada, 2005). This lack of congruence between public health goals and nutrition policies is not unique to Canada. Despite ongoing efforts to promote healthy eating, a recent American supermarket survey found that almost half of the products using food label marketing strategies (primarily nutrient content claims) were high in saturated fat, sodium and/or sugar (Colby et al., 2010).

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Implicit in concerns about the dietary quality of foods eligible to be fortified are two assumptions: (1) that manufacturers will use the addition of nutrients as a means to promote their products and (2) that this will lead to increased consumption of the foods eligible to be fortified. The link between discretionary fortification and product promotion is evident in the levels of nutrient addition permitted under Health Canadas proposed policy; by design, discretionarily fortified foods will qualify for front-ofpackage nutrient content claims highlighting these products as a good or excellent source of the permitted nutrients. Although it seems unlikely that manufacturers will voluntarily add nutrients to foods unless this confers a market advantage for them, there is limited published evidence of the effect of discretionary fortification on product sales or food consumption patterns. A 1987 study documented an increase in market share with increased nutrition messaging in the United States (Levy and Stokes, 1987), but since then, the use of nutrition marketing on food labels has become much more prevalent (Elliott, 2008; Colby et al., 2010). Even if discretionary fortification does not lead to increased consumption of fortified foods, we have no reason to expect that product promotion on the basis of nutrient additions will discourage consumption of these foods. Insofar as discretionary fortification functions to reinforce existing dietary patterns, this policy will neither improve dietary energy density nor address the widespread low fruit, vegetable and fiber intakes in Canada (Garriguet, 2007b; Health Canada, 2007b), which are believed to be important risk factors for obesity (He et al., 2004) and chronic disease (He et al., 2004, 2006; Hung et al., 2004; Institute of Medicine (IOM), 2005; Dauchet et al., 2009). The development of discretionary fortification policy internationally seems to be largely focused on preventing excessive nutrient intakes (Health Canada, 2005; Coppens et al., 2006). As discussions to develop international standards for discretionary fortification continue (Codex Alimentarius Commission, 2007), it is important that we understand the broader public health implications of discretionary fortification policies on food consumption patterns, particularly in the context of a growing prevalence of obesity.

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Conflict of interest
The authors declare no conflict of interest.

Acknowledgements
We gratefully acknowledge Dr George Beaton for his invaluable contributions to this paper. Jocelyn E Sacco holds a Canadian Institutes of Health Research (CIHR) Fellowship in Public Health Policy, and a CIHR Canada Graduate Scholarship Doctoral Award.

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