Fortification masks our deplorable dietary circumstances

paper published in the Journal of the Academy of Nutrition and Dietetics (formerly the American Dietetic Association) highlights the importance of nutrient fortification to the diets of our children. The researchers used data from the National Health and Nutrition Examination Survey to determine the sources of micronutrients in the diets of over 7,000 kids ages 2 to 18, and assessed overall dietary intake in this cohort assembled to represent the population at large.

The basic finding was that nutrient intake levels below the estimated average requirement (one of the thresholds, along with the more familiar recommended dietary allowance, used in the dietary reference intakes developed by the Institute of Medicine) were occasional despite fortification, but would have been very widespread in the absence of it. The findings pertained to fat-soluble vitamins, water-soluble vitamins, and minerals.

The authors conclude their paper by pointing out, correctly, that fortification under current circumstances is important to the nutritional adequacy of the typical child’s diet in the United States. But with all due respect to the team, they fail to take the next step and say: this means that current dietary circumstances in the United States are pretty deplorable.

There is, to be sure, an important role for fortification in public health nutrition. Although we call vitamin D a vitamin, it is really a hormone. Under the native conditions of Homo sapien existence, cholecalciferol is produced by our skin in the presence of sunlight, and activated by our liver and kidneys into what we refer to as active vitamin D3. Only in the absence of adequate sun exposure does vitamin D revert to nutrient status.

But since few of us live outdoors under an equatorial sun, we all live mostly covered up by clothes, and those of us in northern latitudes go several months with negligible sun exposure — an important nutrient it now is. Widespread vitamin D deficiency manifesting as rickets was a well documented consequence of child labor during the Industrial Revolution, and only the routine fortification of dairy put an end to the calamity.

There are other excellent examples of the public health value of fortification as well, but the illustration serves. Fortification has its place.

But it seems to me the new paper stops short of the finish line in its conclusions, and allows far too readily for a pat on the back of the food companies doing the fortification. The authors fail to note the findings warrant a slap across the face of our culture, accompanied by a hearty: snap out of it!

What does it mean when our sons and daughters would commonly be deficient in a range of vitamins and minerals in the absence of willful additions of these nutrients to their foods? It means their foods are natively lacking the nutrients. It means their foods are, all too often, junk.

Prior evidence tells us exactly that. Research has shown that the percent of total calories derived from what would routinely be regarded as “junk food” has risen to account for as much as 50 percent of our kids’ total intake. And even this may allow for favorable distortion, because ready-to-eat cereal is not routinely included in the junk food category. Personally, however, I am pretty dubious about calling multicolored marshmallows “part of a complete breakfast.” Yes, I suppose they are “part” of it all right — I leave you to infer which part. And these are the very kinds of foods where fortification is playing its salient role.

So the complete story is: we’ve built a food supply for ourselves and our kids increasingly out of nutrient-deficient junk, but make it okay by tossing multiple nutrients into the vat of glow-in-the-dark gloop before the mixing is done. The prevailing diet of our daughters and sons is comprised of foods so nutrient poor that absent fortification, they would not be getting the nutrition they need from food. That we, as a nation of loving parents and grandparents, are willing to go along with this does not reflect well on us.

For one thing, consider that fortified junk food is still junk food. It isn’t only what a food doesn’t contain (i.e., those nutrients) that makes it dubious. It’s what it does contain. The addition of vitamins and minerals does nothing to exonerate junk foods of their standard provisions of added sugars, added salt, artificial flavorings, artificial colorings, inflammatory fats, high glycemic starches and willfully irresistible calories.

Imagine if there were economic advantages in constructing airtight houses with all of the breathable air sucked entirely out and replaced with barely breathable, noxious fumes. Instead of conceding this is something of a calamitous boondoggle, we are told: good news! Breathing actual air is yesterday’s news. Your entirely atmosphere-deficient, modern home is fortified with personal oxygen masks for all inhabitants!

Oxygen masks can keep us alive when oxygen is otherwise missing — and of course, we rely on just that in space and under the water. But pure oxygen is highly toxic and all high-flow oxygen delivery systems are intended for short-term use. We might reasonably infer that such a “fortified” home would be rather less salutary over time than an old-fashioned home with old-fashioned, breathable air.

Consider, as well, the irony: we recently got a bumper crop of high-profile commentaries in both scientific and pop culture publications telling us all to dump our worthless nutrient supplements. This was hyperbolic nonsense to begin with — but that much more so in light of this new study. Within weeks of learning we should dump our supplements, we learn that without fortification- essentially, nutrient supplements mixed into the big vats of Big Food — our kids would be suffering widespread nutrient deficiencies. So, is the memo here that those same nutrients accompanied by the junk that often serves as their delivery vehicle are good, but the nutrients on their own are somehow bad? Personally, I’ll take nutrients on their own and leave out the glow-in-the-dark marshmallows, thank you very much.

But then again, I will take foods that are endowed by nature with nutrients as my first choice. Real food.

Nutrients, nutrition and food are supposed to go together. Food is supposed to be sustenance. That we have propagated a food supply that is otherwise says something about our cultural priorities. And while it’s true we can rely on fortification to prevent overt nutrient deficiencies, we need only look around to see what reliance on nutrient-fortified junk has wrought: epidemic childhood obesity, epidemic diabetes and worse.

Fortification under current circumstances is important. So we should be fortifying our cultural opposition to current circumstances. Optimal dietary patterns, comprised of real foods naturally rich in both the nutrients we measure routinely and those we don’t, are associated with optimal health outcomes. Even within any given food category, trading up to more nutritious foods consistently is associated with reduction in the risk of chronic disease and premature death. Nutrient-fortified junk food, however, is the nutritional equivalent of lipstick on a pig.

There are times, looking on for years and decades at our culture as it ignores the well-established fundamentals of wholesome foods and healthful diets, as we line up again and again for flash-in-the-pan fads and then find someone or something to blame for all our ills – that my faith in us is, I regret to say, rather challenged. There are times I worry that all genuine efforts to disseminate good information about good nutrition may suffer the fate of pearls before swine. I really hope not. But if so, we certainly know the result: a diet of lipstick on a pig, for breakfast, lunch and dinner. Bon appétit.

David L. Katz is the founding director, Yale-Griffin Prevention Research Center. He is the author of Disease-Proof: The Remarkable Truth About What Makes Us Well.

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