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Vitamin D has successfully fortified milk products, bread, orange juice, etc. – meta-analysis Dec 2023

Strategic food vehicles for vitamin D fortification and effects on vitamin D status: A systematic review and meta-analysis of randomized controlled trials

Journal of Steroid Biochemistry and Molecular Biology https://doi.org/10.1016/j.jsbmb.2023.106448

There has been growing interest in the potential of vitamin D food fortification in Europe as a means of addressing low vitamin D status. The WHO-FAO suggest that choosing a suitable food vehicle and ensuring the combination of the food vehicle and the fortificant will be efficacious and effective are of key importance to a successful food fortification program. Our key objective was to conduct a systematic review and meta-analysis to investigate the effect of various animal- and plant-based food vehicles fortified with vitamin D (as D3 or D2) on circulating 25-hydroxyvitamin D [25(OH)D] concentrations. A list of prioritized food vehicles was established and we searched PubMed, Embase, Scopus and Web of Science for randomized controlled trials (RCTs) which used these vehicles individually, and which met prespecified criteria.
The searches identified 49 papers which described suitable RCTs using vitamin D-fortified

  • bread/savoury biscuits (n=5),
  • orange juice (n=5),
  • UV-mushrooms (n=8) (not statistically significant),
  • cheese (n=3),
  • yogurt (n=5),
  • fluid milk (n=13),
  • powdered milk (n=5),
  • eggs (n=2),
  • edible oils (n=4), or
  • breakfast cereal (n=1).

No suitable RCTs were identified for

  • rice, maize flour, butter, margarine or dairy spreads, plant-based milk or yogurt alternatives.

Random-effects meta-analyses of each food vehicle individually indicated weighted mean differences (WMD) in 25(OH)D in the range ~9-35 nmol/L (3-15 RCT arms, depending on vehicle), and all statistically significant (P<0.01-0.0001), with the exception of UV-mushrooms (P=0.06). Heterogeneity was variable (I2=33-99%, depending on vehicle), but subgroup analysis based on vitamer and dose reduced it in some instances. Sub-group analysis on the basis of whether the food vehicles were from plant-based or animal-based origin showed no significant difference in WMD (15.2 versus 15.9 nmol/L, respectively; P=0.48). These results support the use of various animal- and plant-based food vehicles for vitamin D fortification to improve circulating 25(OH)D concentrations in populations.

Introduction
Low vitamin D status occurs in populations across the globe but the burden of which varies depending on the world region [1], [2]. There is no one single underlying reason for low vitamin D status, but the combination of low ultraviolet B (UVB) availability and/or exposure coupled with a low dietary vitamin D supply is of key importance [3]. European countries residing above ~40oN experience a ‘vitamin D winter’ of 4 to 7 months during which UVB availability is insufficient to enable synthesis of vitamin D in the skin [4,5). In addition, vitamin D intake data from numerous representative surveys of adults (n=21 surveys) and children (n=13 surveys) across Europe suggest relatively low intakes on average [[6], [7] and consequently, a significant majority have inadequate intakes of vitamin D [3].

The World Health Organisation–Food and Agriculture Organization (WHO–FAO) have suggested that inadequacy of micronutrient intake can be addressed by increasing the diversity of foods consumed, food fortification, and/or supplementation [8]. While each strategy has its merits and challenges, the WHO-FAO have highlighted food fortification because of its wide and more sustained impact, as well as being one of the most cost-effective public health nutrition interventions [8]. It is not surprising that in light of the fact that 1 in 8 Europeans have serum 25-hydroxyvitamin D (25(OH)D) concentrations <30 nmol/L, indicative of increased risk of vitamin D deficiency, and about 40% have concentrations below 50 nmol/L [9], representing risk of inadequacy/insufficiency for some in the population, there has been growing interest in the potential of vitamin D food fortification programmes in Europe [10], [11], [12], [13]. Importantly, the decision on what food(s) to fortify requires careful evaluation [14]. The WHO-FAO suggest that choosing a suitable food vehicle and ensuring the combination of the food vehicle and the fortificant will be efficacious and effective are of key importance to a successful food fortification program [8]. Food vehicles range from basic commodities, such as various types of flour, oil and milk which are available on the retail market for use by consumers as well as ingredients of processed foods, to processed foods that are fortified at the point of manufacture [8]. Vitamin D3, vitamin D2 and very recently, 25-hydroxyvitamin D3 are approved for use in food fortification in Europe [15].

Several systematic reviews and meta-analyses (SR+MA) [16], [17], [18], [19], [20], including a recent umbrella systematic review [21], have expertly synthesised the available data from randomized controlled trials (RCTs) in relation to the efficacy and effectiveness of vitamin D-fortified foods in terms of improving vitamin D status in healthy individuals, as reflected by increases in serum 25(OH)D. However, these SR+MA for the most part focused on vitamin D-fortified foods collectively, irrespective of food vehicle type, and accordingly have pooled all vitamin D-fortified foods together in their respective meta-analyses. In the SR+MA by Nikooyeh & Neyestani [19] as well as the primary pooled analysis of data from 32 RCTs, a subgroup analysis based on the type of vitamin D-fortified food showed that the food vehicle had a significant (P=0.01) effect. Of note, a significant majority (63-81%) of RCT arms within these SR+MA used dairy-based foods as the vitamin D intervention [16], [17], [18], [19], [20]. There has been a recent emphasis on increased consumption of plant-based foods and reductions in dairy and meat for many as part of a more sustainable flexitarian-type diet [22], underscoring the need to consider potential food vehicles for vitamin D fortification more widely going forward. Thus, the objective of the present SR+MA was to examine the evidence-base around the response of serum 25(OH)D to consumption of individual types of animal- and plant-based food vehicles fortified with vitamin D, including a delineation by vitamin D3 and D2 as fortificant, where feasible.

Section snippets
Identification of food vehicles for inclusion in electronic searches
A list of food vehicles for vitamin D fortification to be used in electronic searches in the present systematic review (SR) was generated firstly, by consultation of the Global Fortification Data Exchange portal in terms of food vehicles with vitamin D in country standards [23]; secondly, a search of existing SRs of vitamin D-fortified foods [16], [17], [18], [19], [20], [24], [25]; and thirdly, a web-based market analysis of foods with added vitamin D that were commercially available in…

Literature searches and study quality
Systematic electronic searches retrieved 1486 publications, of which 290 were duplicates (Fig. 1). Following title and abstract screening, potentially relevant papers remained and the full text of which were carefully examined. Of these, 35 were excluded for various reasons, whereas 49 papers met the inclusion criteria [35], [36], [37], [38], [43], [44], [45], [46], [47], [48], [49], [50], [51], [52], [53], [54], [55], [56], [57], [58], [59], [60], [61], [62], [63], [64], [65], [66], [67], [68]…

Discussion
The WHO-FAO guideline on food fortification suggests that ensuring the combination of the food vehicle(s) and the fortificant will be efficacious and effective is key in terms of successful food fortification [8]. While there have been several comprehensive SRs of the effect of vitamin D-fortified foods on serum 25(OH)D, these for the most part have pooled all vitamin D-fortified foods together in their respective meta-analyses [16], [17], [18], [19], [20]. In contrast, and by design, the…

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VitaminDwiki – Fortification with Vitamin D contains

131 items in Fortification category

Fortification works, even if food is cooked, but govts rarely fortifiy with enough
Govts, food producers, and families can fortify:
   milk,   yogurt,   beer,   bread,  cereals,  cooking oil,  soups,  jams,   jellys,   honey,   snack bars, etc.
Some interesting fortification articles

VitaminDwiki – Bread Fortification contains

VitaminDWiki Fortification pages with BREAD in title

This list is automatically updated

Items found: 13

VitaminDwiki – Change of Vitamin D Fortification in Denmark contains


Vitamin D has successfully fortified milk products, bread, orange juice, etc. – meta-analysis Dec 2023        
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