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Dear Dr Cannell: To fortify or not to fortify

Posted on: August 22, 2012   by  John Cannell, MD


Dear Dr. Cannell:

I suspect that a great proportion of those taking a supplement only take the officially recommended level of 400 IU up to 1000 IU, so having little effect on blood levels and their health. It is the recommendation that baffles me! “Food-based strategies, including fortified foods, need to be explored.” Hasn’t this approach really failed in the US?

How can you get the required levels up by adding a bit to milk? Or even bread? How can that be controlled given the diets of the average American or Irishman or New Zealander? The “add a bit to food” is fine if you want to prevent rickets but we now know that adequate levels of around 50-70 ng/ml are required/normal for full protection against many modern diseases.

Surely two things must be at the basis of an extensive public health promotion:  In the summer get more sunshine and in the winter, take a supplement of 5000 IU per day.

Sally, New Zealand

Dear Sally:

Adequate food fortification will not solve the problem but has the potential to do enormous good. Remember, most studies show raising your level from 5 ng/ml to 20 ng/ml is where most (not all) of the good is done.

In the USA, food fortification has failed because of dose and the food we fortify the most, milk. Many of the people with very low levels, such as Blacks, seldom drink milk due to fear of lactose intolerance. These days, mothers usually wean toddlers on juice and not milk. However, both Blacks and toddlers eat cheese, cereal, yogurt, juice, bread, cookies, eggs, butter, and meat at the same frequency as white adults.

In tackling this public health problem, as many approaches as possible are needed. Supplementation and sun exposure by people like you and other health conscious persons is very important. Those taking a 400 IU supplement will eventually increase their dose as more research comes out. However, we cannot ignore the 50% of people who will not take a supplement or sunbathe.

For those people, food fortification of multiple foods will do tremendous good, although in my opinion, few will obtain natural vitamin D levels from food fortification.  Say there was a 200 IU/serving in cheese, yogurt, juice, cereal, bread, meat, cookies, eggs, butter, and even beer (as was done in the USA in the 1930s). Many people would get a 1,000 IU/day or even more from food and that would be a very good thing.

In the next ten years, the best we could hope for with food fortification is to get 97% of people above 20 ng/ml. While inadequate, it is so much better than 5 or 10 ng/ml that it is not a failure just because it is not perfect. Why the recent Food and Nutrition Board did not recommend food fortification to get Blacks and toddlers above their lower limit of 20 ng/ml, is any one’s guess. While perfect is better than good, remember what Voltaire said: “Perfect is the enemy of good.”

7 Responses to Dear Dr Cannell: To fortify or not to fortify

  1. [email protected]

    ” 50% of people who will not take a supplement”?
    Is there some reference which documents that?
    I can believe that 50% of the people do not take pills daily because:
    1) Expense
    2) Have not learned how to swallow pills
    3) Do not remember to take pills, so they do not try

    None of those problems exist with vitamin D
    1) Less than 1 cent per day when using 50,000 IU capsules
    2) Can use sublingual or liquid forms – for about 5 cents per day
    3) Can just put a reminder on their calendar to take the vitamin D
    example: every other Saturday

    Reminder: US seniors take , on-average, 5 prescription medicines (usually as pills) each year.

  2. Jim Larsen

    Generally about 40-50% of prescriptions go unfilled.

    My doc is very pro D, but many patients just aren’t interested.

    Some restaurants sell a meal called the “heart attack special.”. It typically sells well.

    The 5 year failure rate for weight loss programs is over 90% because folks don’t change their behavior.

    And so it goes. BTW the CDC says most kids no longer drink milk.

  3. Ron Carmichael

    “generally about 40-50% of prescriptions go unfilled” – thank gawd.
    As a pharmacist, I know that most prescriptions are “make the patient happy and get them the heck out of my face” medications. In the case of Rx for vitamin D, the vast majority in my personal experience (299 out of 300 or so) are for Drisdol. (vitamin D2). BAD D. Since most pharmacists are just like the rest of the US population, they are clueless about the relevance of vitamin D3 in chronic diseases of a vast variety. Speaking of “vast variety”, the vast majority of citizens do NOT go to a heart attack special eatery, especially on a routine basis. Once a year, what’s the harm? Offset it with 364 days or so of fruits, vegetables, berries, and good sun exposure and I’ll be in line with you for one of those bad boys….. 🙂
    But once a week, and I’m trying out for the cardiac cath lab olympics!

  4. Ian

    Dr. Cannell’s analysis is quite right. Food fortification has an important role to play.
    In relation to melanoma and other skin cancers: Would a person reduce their risk of skin cancer by taking a vitamin D supplement in the winter months in preparation for higher sun-exposure in the summer, at which time they might reduce or stop their vitamin D supplementation? If yes then what would be the required dose in order to maximise the preventative value of the winter D?

    Would the amount obtained from ideal food supplementation as Dr. Cannell described (leading to around 1000IU) help to reduce this skin cancer problem?

  5. Jim Larsen

    “Compliance” is a studied issue. Docs wrestle with trying to get patients to do anything healthy.

    Informing docs that prescription D3 is now available is an education issue.

    If you look at weight loss program 5 year failure rates, they are above 90%. The 2 year failure rate with bariatric surgery is around 30%. So changing human behavior is very difficult.

    The issue with the “heart attack” special is not that the food actually causes a heart attack, it’s that people buy a meal called the “heart attack special.”

    I’d like to see your data on the vast majority not eating unhealthy meals, because the CDC/USDA data is most meals are eaten out (in fact I think their data is low) and the Standard American Diet is 69% processed carbs.

    I agree that lots of vegetables, fruits, etc. are the best way to go. Sun is wonderful if you’re below Atlanta in latitude, under 50, not obese, not dark skinned, etc.

    The bottomline is Dr. C. is correct. You cannot assume the population can flock to healthy solutions. I’m not saying they don’t want to, but the reality is that single parents and dual income families are a high percent of the population, folks spend hours/day commuting, and almost 1/3 of the US earns less that $25k. Folks are using meals and sleep as the bill payers for busy lives. How many pro D folks are here compared to 312 million folks in the US?


    Food fortification has historically been successful (B in grains, D in milk, and iodine in salt), but changing behavior is affecting those programs. Folks are going low carb, avoiding salt, and not drinking milk. Remember food fortification is not applied to all products (e.g. only consumer salt is fortified).


    The RCT data says 2,000-4,000 iu/day would get most folks up to good D levels over a few months. The question then is how much D in what foods? Realizing folks will be concerned about the outliers re overdoses. What if a lifeguard drinks 10 sodas/day with 500iu/soda? Etc.

  6. Ron Carmichael

    Fortification? It depends on some balances as to what you think you will accomplish?
    Free vs. increments? Which is ultimately of best “good”: Changing the conviction people have which is based on lies? or, cause the price for commodities to go up slightly and imbue them with a false security of a physiologically insignificant, impotent amount of a known necessary nutrient?
    The need of each person varies on sunlight availability(Glasgow vs. London), on outdoor activity (plays soccer 3 days a week vs. runs 3 miles at 6am each day), on skin type (red head, totally unable to tan vs. a brown haired,brown eyed caucasian able to pass as hispanic after the first week of spring), with a mother who either insists on sunscreen or is clueless about protecting from burns, all of which are actually far more good reasons for NOT relying only on fortifying food(s). It is ludicrous to worry about overdosage of vitamin D3 except in Rx miscalculations, so putting in foods is good, as long as the message to the public is to GET SOME SUN WHEN IT COUNTS, AND TO TAKE SOME EXTRA THOUSANDS IU PER DAY IN THE WINTER, OR ALL YEAR ROUND, depending on locale and lifestyle. And know that the risk of getting too much for the typical adult of getting 10,000iu per day seems to be very low based on the published studies to be considered.

  7. [email protected]

    I agree with Ron Carmichael. Fortifying foods will only lull people into thinking that they are receiving an adequate amount of vitamin d from diet, when we know that the Standard American Diet is a basically a cold cut sandwich, bag of chips and a sprite. So, even if we fortify foods appropriately, we then must hope that the public vastly improves its daily food selection. And even under the best of diets, with appropriately fortified food, I think many will still fall short of consuming enough of the fortified foods to substantially raise their d levels. In short, there will be a false sense of security among the public: “Oh Vitamin D? I don’t need that. I eat healthy!” BIG MISTAKE, GUYS!!!!
    Food fortification? Yes, but it is not the complete answer. Only partial answer at very best. The message must include appropriate amounts of sun, and additional THOUSANDS IU per day of d3 in the winter and/or all year long, depending not only on locale and lifestyle, guys, but also on the individual’s particular set of health conditions.

    To rely on d3 thru food, or thru sun, or thru supplements? These aren’t the questions to ask. The questions to ask are: 1. how can we improve physicians’ knowledge of vitamin d; 2. how can we raise the minium daily requirement of d?; 3. how can we get testing of d serum to be included AS STANDARD just as doctors test routinely for thyroid, glucose or lipids; and 4. how can we demand that deficiency is corrected, just as doctors aim to correct health problems associated with cholesterol, thyroid or blood sugar.

    After all, correcting d deficiency may actually take care of the rest of those very common health problems…. I am not in the health care profession. I speak only from the heart and from common sense.

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