evaluating the prevalence, nutritional quality, and …...evaluating the prevalence, nutritional...
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Evaluating the prevalence, nutritional quality, and marketing
characteristics of nutritionally-enhanced foods in Canada
by
Sheida Noorhosseini
A thesis submitted in conformity with the requirements
for the degree of Master of Science (M. Sc.)
Graduate Department of Nutritional Sciences
University of Toronto
© Copyright by Sheida Noorhosseini 2016
ii
Evaluating the prevalence, nutritional quality, and marketing
characteristics of nutritionally-enhanced foods in Canada
Sheida Noorhosseini
Master of Science (M.Sc.)
Nutritional Sciences
University of Toronto
2016
Abstract
Nutritionally-enhanced foods are a fast-growing sector of the global food industry. Concerns
have been raised that the consumption of these products may have negative repercussions on
population health, such as high nutrient intakes inappropriate for certain population subgroups
(e.g. children) and the shifting of dietary patterns to include more unhealthy foods. This thesis
aimed to evaluate the prevalence, nutritional quality, and marketing characteristics of foods with
added nutrients in the Canadian market. Many nutritionally-enhanced foods contained high
levels of nutrients beyond recommended intakes, despite these nutrients having no evidence of
inadequacy in the Canadian population. Additionally, a large proportion of foods with added
nutrients had poor nutrient profiles and carried heavy marketing on their labels, regardless of
their nutritional quality. These findings support concerns surrounding the consumption of foods
with added nutrients and suggest the need to further evaluate these concerns by investigating
consumer attitudes and decision-making towards these foods.
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Acknowledgements
I would like to express my gratitude to everyone who has helped me on my journey as a Master’s
student. First and foremost, I would like to sincerely thank my supervisor, Dr. Mary L’Abbé. I
came into this program with almost no prior knowledge in nutrition and I have come a long way
thanks to the support and guidance of my supervisor. She has shared with me her knowledge and
wisdom in a way that has not only helped me to write this dissertation and feel like I have
contributed to the research community, but also in a way that has helped me grow as a student, as
a researcher, and as a person to reach where I am today. I would also like to thank her for being a
genuinely kind and caring person who, despite her busy schedule, views her students as her
number one priority and ensures that they receive all the help that they need to succeed.
I am also very grateful for the feedback and support that my thesis advisory committee—Dr.
Heather Boon, Dr. Joanne Arcand, and Dr. Deborah O’Connor—has given me over the course of
my studies, helping me to challenge myself and expand my ideas to improve my work. I would
also like to thank my wonderful labmates: Jodi Bernstein, Mary Scourboutakos, Mahsa Jessri,
Mavra Ahmed, Marie-Eve Labonté, Beatriz Franco, Alyssa Schermel, and Theresa Poon, for
their friendship and invaluable advice. Finally, I am eternally grateful to my family and friends
for giving me their constant support and love.
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Table of Contents
Abstract ........................................................................................................................................... ii
Acknowledgements ........................................................................................................................ iii
Table of Contents .......................................................................................................................... iiv
List of Tables ................................................................................................................................ vii
List of Appendices ....................................................................................................................... viii
List of Abbreviations .................................................................................................................... iix
Chapter 1 ....................................................................................................................................... 1
1 - Introduction ........................................................................................................................... 1
1.1 Overall rationale................................................................................................................ 1
Chapter 2 ....................................................................................................................................... 3
2 - Literature review ................................................................................................................. 3
2.1 Regulatory history of the addition of nutrients to foods in Canada .................................. 3
2.1.1. Mandatory and voluntary fortification ...................................................................... 3
2.1.2. Discretionary fortification ......................................................................................... 4
2.1.3. “Food-like” natural health products .......................................................................... 5
2.1.4. Transition of food-like natural health products to the food regulatory framework .. 6
2.1.5. Supplemented foods and functional foods ................................................................ 6
2.2 Prevalence of nutritionally-enhanced foods ...................................................................... 7
2.2.1 Voluntarily fortified foods ......................................................................................... 7
2.2.2. Supplemented and functional foods .......................................................................... 7
2.3 Nutrition marketing on food labels of nutritionally-enhanced foods ................................ 8
2.3.1. What is nutrition marketing? .................................................................................... 8
2.3.1.1. Nutrient content claims ...................................................................................... 9
2.3.1.2. Health Claims..................................................................................................... 9
2.3.1.3. Front-of-pack (FOP) labelling ......................................................................... 11
2.3.2. Influence of nutrition marketing on consumer attitudes ......................................... 12
2.3.3. Prevalence of nutrition marketing on prepackaged foods with added nutrients ..... 13
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2.4 Nutrient profiling of nutritionally-enhanced foods ......................................................... 13
2.4.1 What is nutrient profiling? ....................................................................................... 13
2.4.2 FSANZ Nutrient Profiling Scoring Criterion (NPSC) ............................................. 14
2.4.2.1. Overview of FSANZ Nutrient Profiling Model (NPSC) ................................. 15
2.4.3 The nutritional quality of nutritionally-enhanced foods .......................................... 17
2.5 Concerns surrounding nutritionally-enhanced foods ...................................................... 18
2.6 Scope and objectives of thesis ........................................................................................ 20
Chapter 3 ..................................................................................................................................... 22
3 - Study 1: The prevalence, nutritional quality, and marketing characteristics of
supplemented foods and functional foods in the Canadian marketplace .................................. 22
3.1 Abstract ........................................................................................................................... 23
3.2 Introduction ..................................................................................................................... 23
3.3 Methodology ................................................................................................................... 25
3.3.1 Data collection ......................................................................................................... 25
3.3.2 Data analysis ............................................................................................................ 26
3.4 Results ............................................................................................................................. 29
3.5 Discussion ....................................................................................................................... 52
Chapter 4 ..................................................................................................................................... 58
4 – Study 2: The nature and prevalence of voluntarily fortified foods with high levels of added
vitamins and minerals in the Canadian marketplace ................................................................. 58
4.1 Abstract ........................................................................................................................... 58
4.2 Introduction ..................................................................................................................... 59
4.3 Methodology ................................................................................................................... 60
4.3.1 Data collection ......................................................................................................... 60
4.3.2 Data analysis ............................................................................................................ 61
4.4 Results ............................................................................................................................. 62
4.3 Discussion ....................................................................................................................... 73
Chapter 5 ..................................................................................................................................... 77
5 - General Discussion .............................................................................................................. 77
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5.1 Overview of findings ...................................................................................................... 77
5.2 General discussion .......................................................................................................... 79
5.3 Conclusion ...................................................................................................................... 84
References ..................................................................................................................................... 86
Appendices .................................................................................................................................... 94
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List of Tables
Table 1. Prevalence of supplemented foods* (SFs) in the Canadian marketplace in 2013 ......... 33
Table 2. Levels of added vitamins and minerals in the most common supplemented food*(SF)
categories .............................................................................................................................. 34
Table 3. Added caffeine and amino acids in supplemented foods* (SFs) in Canada in 2013 ..... 36
Table 4. Prevalence of functional foods* (FFs) in the Canadian marketplace in 2013 by food
subcategory ........................................................................................................................... 37
Table 5. Ingredients added to functional foods in the Canadian food market in 2013 ................ 39
Table 6. Comparison of NPSC nutrient profile scores* of supplemented foods¥ (SFs) and non-
supplemented foods (non-SFs) in the Canadian marketplace in 2013 .................................. 40
Table 7. Number and proportion of SFs* and non-SFs meeting ‘healthy’ cutpoints based on the
FSANZ NPSC system¥ ......................................................................................................... 41
Table 8. NPSC nutrient profile scores* of functional foods¥ (FFs) and non-functional foods
(non-FFs) in the Canadian marketplace in 2013 ................................................................... 42
Table 9. Number and proportion of FFs* and non-FFs meeting ‘healthy’ cutpoints based on the
FSANZ NPSC system¥ ......................................................................................................... 44
Table 10. Breakdown of NPSC scores¥ of functional foods (FFs)ǂ compared to non-functional
foods (non-FFs) per food subcategory .................................................................................. 45
Table 11. Level of nutrition marketing on food labels of supplemented foods* (SFs) and non-
supplemented foods (non-SFs) in Canada in 2013 ............................................................... 49
Table 12. Level of nutrition marketing on food labels of functional foods* (FFs) and non-
functional foods (non-FFs) in Canada in 2013 ..................................................................... 50
Table 13. The prevalence of voluntarily fortified foods with high levels of added vitamins and
minerals (VHVMs) in the Canadian market in 2013 ............................................................ 65
Table 14. Vitamins and minerals present in VHVMs* in the Canadian market in 2013 ............. 67
Table 15. Comparison of FSANZ nutrient profiling scores* of VHVMs¥ and non-VHVMs in
Canada in 2013. .................................................................................................................... 68
Table 16. Number and proportion of VHVMs* and non-VHVMs meeting ‘healthy’ cutpoints
based on the FSANZ NPSC system¥. ................................................................................... 70
Table 17. Levels of nutrition marketing on VHVMs* compared to non-VHVMs in Canada in
2013....................................................................................................................................... 71
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List of Appendices
Appendix 1. Method for calculating FVNL content of foods using the Ingredients List ............ 94
Appendix 2. Ingredients that can be added to nutritionally-enhanced foods ............................... 95
Appendix 3. List of all supplemented foods (SFs) and ingredients in the FLIP 2013 ................. 97
Appendix 4. Standardized method used to calculate FSANZ nutrient profiling score (NPSC)
using data in the Canadian FLIP 2013 database ................................................................. 102
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List of Abbreviations
AI – Adequate Intake
AMDR – Acceptable Macronutrient Distribution Range
CCHS – Canadian Community Health Survey
CFIA – Canadian Food Inspection Agency
CNF – Canadian Nutrient File
DRRC – Disease Risk Reduction Claim
DV – Daily Value
FDR – Food and Drug Regulations
FF- Functional Food
FLIP – Food Label Information Program
FOP – Front-of-Pack
FSANZ – Food Standards Australia New Zealand
FVNL – Fruit/vegetable/nut/legume
NCD – Non-communicable diseases
NFt – Nutrition Facts Table
NHP – Natural Health Product
NHPR – Natural Health Products Regulations
NPSC – Nutrient Profiling Scoring Criterion
RDA- Recommended Daily Allowance
RTE – Ready-to-Eat
SF – Supplemented Food
TMA – Temporary Marketing Authorization
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TMAL – Temporary Marketing Authorization Letter
UL – Tolerable Upper Level
USA – United States of America
VHVM – Voluntarily fortified foods with high levels of vitamins and minerals
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Chapter 1
1 - Introduction
1.1 Overall rationale
As national and global rates of obesity and diet-related noncommunicable diseases (NCDs)
continue to rise (1, 2), consumers worldwide are becoming more aware of the relationship
between diet and health and are demanding more foods and beverages with nutritional
enhancements that are beneficial to physical and mental well-being (3, 4). In Canada, this has led
to the proliferation of foods containing added vitamins, minerals, herbals, bioactives, amino
acids, novel fibres, and other substances in the food market. Depending on the type and amount
of substances that are added, these foods are referred to as supplemented foods (SFs), functional
foods (FFs), or foods with voluntary additions of high levels of vitamins and minerals (VHVMs).
Researchers and health professionals have raised concerns that the use of these products may
have detrimental effects on population health. If consumers perceive SFs, FFs, and VHVMs as
healthier due to their added ingredients—particularly if they are heavily marketed—without
considering other nutritional aspects (e.g. sugar, fat, or sodium content) of the food, they may
inadvertently make unhealthy dietary choices and negatively impact their eating patterns. In
addition, the consumption of foods with added vitamins, minerals, and other micronutrients,
especially in combination with supplement use, may lead to excessive intakes that exceed Upper
Levels (ULs) and/or are not appropriate in certain population subgroups, such as children and
adolescents (5).
There is currently a lack of data on the prevalence and nature of nutritionally-enhanced foods in
Canada. Therefore, the objective of this thesis was to examine and evaluate the frequency,
nutritional quality and marketing characteristics of SFs, FFs, and VHVMs in the Canadian
market in 2013 using the University of Toronto Food Label Information Program (FLIP) 2013, a
food database containing information on over 15,000 foods and beverages sold in major
Canadian grocery stores. In Study 1, the prevalence and nature of SFs and FFs were evaluated.
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In Part I of this study, the frequency and proportion of SFs and FFs in each food category, and
the type and/or amount of added nutrients in SFs and FFs was assessed. In Part II of this study,
the nutritional quality of SFs and FFs was determined using a validated nutrient profiling model.
Nutrient profile scores were then compared between foods with added supplemental or
functional ingredients and comparable conventional foods without these additions. The number
of nutrition-related claims occurring on food labels of SFs and FFs was also examined. Study 2
specifically examined foods with high levels of voluntary addition of vitamins and minerals. The
frequency of VHVMs and the types of foods that were most likely to contain high levels of
vitamins and minerals added through voluntary fortification were determined. Additionally, the
nutrient profile scores and number of nutrition-related claims were compared between VHVMs
and foods that did not contain high levels of voluntary fortification. The findings of this thesis
provides baseline data on nutritionally-enhanced foods in Canada and can help formulate future
research examining the consumption patterns of these foods in the Canadian population and
possible areas where policy or regulatory changes may be needed to address these concerns
surrounding the availability and use of these foods.
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Chapter 2
2 - Literature review
2.1 Regulatory history of the addition of nutrients to foods in Canada
2.1.1. Mandatory and voluntary fortification
Vitamin deficiency as a cause of disease was first observed in Canada in the early 1900s in
segments of the population with beriberi and blindness in Newfoundland and Labrador (6). Since
this discovery and additional documentations of vitamin deficiency across the country, the
Canadian government has implemented the fortification of foods with vitamins and minerals as a
method to address and eliminate these deficiencies and the illnesses associated with them.
Synthetic vitamins first became available for addition to foods with no restrictions in the 1930s
and 1940s (7). As many of these foods began to carry nutrition related claims that were deemed
to be exaggerated and misleading, concern about fraudulent practices prompted the Canadian
government to enforce regulations in 1941 restricting the types of claims that could appear on
products, and minimum and maximum levels of vitamin addition were introduced in 1942 and
1949 respectively (7). In the 1940s and 1950s, the addition of iodine to salt essentially eliminated
the condition of goiter in Canada, and vitamin D fortification was used to address the high
incidence of rickets throughout the country (7). In the case of vitamin D, a survey conducted in
Ontario in 1963 suggested that children had very high daily intakes of vitamin D due to a
combination of a variety of fortified foods and supplements (8). This led to a change in
regulations prohibiting the addition of vitamin D to most food products, and inadvertently
resulted in an increase in the incidence of rickets (8, 9). Experiences with vitamin D fortification
prompted Health Canada to create a “positive listing” approach to food fortification in the
updated regulatory provisions made in 1964 (7). The Food and Drug Regulations (FDR) include
a list of foods that must be fortified with vitamins, minerals or amino acids at specified levels,
and prohibits the addition of a micronutrient to foods that is not included in this list or in an
amount that falls outside the specified range for a particular nutrient (10). Under current
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regulations, nutrients may be added to foods in Canada for purposes consistent with the Codex
General Principles for the Addition of Essential Nutrients to Foods, including: “i)
preventing/reducing the risk of, or correcting, a demonstrated deficiency of one or more essential
nutrients in the population; ii) reducing the risk of, or correcting, inadequate nutritional status or
intakes of one or more essential nutrients in the population; iii) meeting requirements and/or
recommended intakes of one or more essential nutrients; iv) maintaining or improving health;
and/or v) maintaining or improving the nutritional quality of foods” (11).
This approach to food fortification is regarded by Health Canada as a successful fortification
program that both ensures the prevention of nutrient inadequacies and protects against excessive
nutrient intakes in the population (7, 9).
In addition to the mandatory fortification of certain foods—for example the addition of vitamins
A and D to margarine—the addition of vitamins and/or minerals is optional or “voluntary” for
certain other foods. An example of voluntary fortification includes the addition of B vitamins to
breakfast cereals. As with mandatory fortification, voluntary fortification permits the voluntary
addition of micronutrients so long as they comply with the type and amount set out in the FDR
(10).
2.1.2. Discretionary fortification
From 1998 to 2005, Health Canada began a series of consultations to review its food fortification
policies. This process was initiated in response to concerns that the policies regarding the
addition of vitamins and minerals to foods in Canada were too restrictive and limited the
development of new food products and the opportunity to provide Canadians with a wider
variety of fortified food choices (7). After a lengthy and multifaceted process, draft regulations
were published in 2005 in the Addition of Vitamins and Minerals to Food, 2005: Health
Canada’s Proposed Policy and Implementation Plan (12). The proposed policy recommended
the expansion of fortification programs to allow for the addition of vitamins and minerals to
foods at the discretion of the manufacturer for the purposes of meeting recommended intakes and
reducing the risk of inadequate nutritional status in the Canadian population (12). By 2009, the
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Minister of Health rejected this proposal due to conflicting stakeholder concerns (13). Health
stakeholders were wary of the potential spread of fortified foods with otherwise substandard
nutritional value and the appearance of claims on these products that could mislead consumers to
make unhealthy dietary choices. On the other hand, the food industry was concerned that the
proposed policies were too inflexible and were not on par with the fortification policies of other
countries, creating barriers to food innovation (13). Due to these concerns, Health Canada began
to review alternative approaches to revising the original fortification principles and create
regulations that allow for a greater variety of foods to contain added nutrients in a safe manner.
As of 2015, Health Canada has not yet published a document on its revised and finalized policies
or regulatory amendments, although several policy documents regarding foods that had been
marketed as natural health products have been released (see 2.1.3).
2.1.3. “Food-like” natural health products
With the stalling of discretionary fortification regulatory changes, food industry manufacturers
sought faster market access for foods with added micronutrients that were not in compliance with
the FDR through the Natural Health Products Regulations (NHPR) (13). The NHPR came into
effect in 2004 to oversee the safety, efficacy and quality of a class of products referred to as
natural health products (NHPs) (14). A NHP is characterized as a substance or combination of
substances set out in Schedule 1 of the NHPR, that is intended to be used either in the diagnosis,
treatment, or prevention of a disease, restoring or correcting biological functions, or to promote and
maintain good health, and includes vitamin and mineral supplements, probiotics, herbal remedies,
homeopathic medicines, traditional Chinese medicines, and other products such as essential fatty
acids and amino acids (14). Although the NHPR was not designed to regulate conventional food
products, as specified in the Regulatory Impact Analysis Statement, NHPs in food format were
not excluded from the scope of the regulations (15). Foods, such as energy drinks, with high
levels of added vitamins, minerals, amino acids, herbals, bioactives and other nutrients that are
not permitted or are in amounts that are greater than what is permitted for addition to foods under
the FDR were able to gain access to the Canadian market as NHPs under the NHPR (13). Several
hundred foods with added micronutrients have since gained market access as NHPs (13).
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2.1.4. Transition of food-like natural health products to the food regulatory
framework
In 2010, Health Canada came to the realization that certain NHPs in food format were being
marketed and used as foods, rather than products intended for therapeutic purposes (13). As a
result, Health Canada published a guidance document (16) to assist regulators in determining
whether or not a product in food format should be classified as a NHP. Revised classification
decisions are based on a series of criteria that distinguish NHPs from foods outlined in the
document (16). For instance, if a product has similar product packaging as a typical food, is
perceived by the public as a food rather than a therapeutic product, and has a historical pattern of
use as a food, then it must now be classified as a food, not an NHP (16). In 2011, Health Canada
began a phased approach—beginning with caffeinated energy drinks (CEDs), followed by
additional food categories—to transition several hundred misclassified products sold under the
NHPR back to the food regulatory framework (13). The transition process was facilitated
through the issuance of Temporary Marketing Authorization Letters (TMALs). Temporary
Marketing Authorization (TMA) allows products that contain an ingredient that is prohibited
under the FDR, but has no immediate safety concerns, to gain market access for a specified
period of time, usually for 2 to 5 years (17). During this time, industry is required to provide
research addressing data gaps and collect the information necessary to create appropriate
regulatory policies and manage potential health risks that are associated with the consumption of
these foods (17). Category specific guidance documents were created to outline the scope and
eligibility of products that could receive TMALs (18, 19). The transition process was completed
in December 2012 (13).
2.1.5. Supplemented foods and functional foods
In the guidance documents for obtaining TMALs, Health Canada refers to a subset of foods as
supplemented foods (18, 19). A supplemented food has been broadly defined as: “a pre-packaged
product that is manufactured, sold or represented as a food, which contains added vitamins,
minerals, amino acids, herbal or bioactive ingredients” which “may perform a physiological role
beyond the provision of nutritive requirements”(20). According to this definition, a
supplemented food would not include foods containing added nutrients in amounts that are
7
permissible for fortification, enrichment, or food additive purposes according to the FDR (20).
Certain public health groups, including Dietitians of Canada, have voiced concerns, such as a
lack of clarity, regarding Health Canada’s proposed definition of a supplemented food (5).
Health Canada has defined a functional food as a food that “is similar in appearance to, or may
be, a conventional food, is consumed as part of a usual diet, and is demonstrated to have
physiological benefits and/or reduce the risk of chronic disease beyond basic nutritional
functions” (21). Some examples of functional foods are foods containing pro- and prebiotics,
phytosterols, novel fibres, protein isolates, omega-3 and omega-6 fatty acids, and other bioactive
substances (21). However, there is currently no strict, regulatory definition of a functional food
or inclusive list of ingredients that are classified as being functional in Canada. From a
regulatory perspective, functional foods are classified as, and included in the same regulatory
framework as conventional foods (22).
2.2 Prevalence of nutritionally-enhanced foods
2.2.1 Voluntarily fortified foods
Voluntarily fortified foods have been shown to greatly contribute to the population intakes of
certain micronutrients, such as iron, in Europe (23). A 2008-2010 survey in Ireland found that
82% of adults reported consuming voluntarily fortified foods, along with more than a 170%
increase in the supply of fortified foods from 1997-1999 to 2008-2010 (24). A study conducted
in the US collected up to two 24-hour dietary recalls per individual on over 8,000 participants
and found that nearly 50% of participants consumed a voluntarily fortified food on either recall
day (25). Although there has been research on the consumption of voluntarily fortified foods
globally, this topic has not yet been investigated in Canada. Additionally, there is a lack of
research on the occurrence of voluntarily fortified foods in Canadian marketplace.
2.2.2. Supplemented and functional foods
There is currently no global definition of a supplemented food or a functional food. As a result,
studies report various results on the prevalence of these foods in the marketplace, since the
8
inclusion and exclusion criteria to define foods as supplemented or functional differ between
studies. However, researchers agree that the nutritionally-enhanced food market is growing
worldwide (26). The global market value of functional foods is estimated to be over USD
61billion (27). In 2013, Japan had the world’s largest market for functional foods, followed by
the USA (27). In Canada, it was reported that the functional food market created a total annual
revenue of over $6 billion in 2011 (28). An analysis conducted on NHPs sold in Canadian
grocery stores between 2010 and 2011 found a total of 66 beverages classified as caffeinated
energy drinks, nutrient-enhanced water beverages, or nutrient-enhanced fruit beverages (29).
Although supplemented foods under current regulations are no longer defined as NHPs, some,
though not all, of the beverages analyzed in the latter study have since been issued TMAs and are
now being sold as supplemented foods (29, 30). Therefore, although the results of this study (29)
can be used to give a snapshot of the number of beverages with added vitamins and minerals on
the Canadian market in 2011, there is virtually no information on the occurrence of
supplemented and functional foods that are currently being sold in Canadian supermarkets.
2.3 Nutrition marketing on food labels of nutritionally-enhanced foods
2.3.1. What is nutrition marketing?
Food manufacturers may employ certain types of nutrition marketing on food labels, such as
nutrient content claims, health claims, and Front-of-Pack (FOP) labelling systems, to
communicate the nutritional content of their foods to consumers. Nutrition marketing has been
defined as any form of marketing of food or beverage products that employs health or nutrition
information that is outside the scope of minimum requirements (31). The minimum food
labelling requirement on most prepackaged foods in Canada is the Nutrition Facts Table (NFt),
which contains information on the serving size, energy value, and nutrient values of thirteen core
nutrients (10). Therefore, any health or nutrition information outside of the NFt can be
considered as nutrition marketing. This includes nutrient content claims, health claims, and
Front-of-Pack (FOP) labelling (32). These forms of nutrition marketing are all considered as
voluntary labelling (32). From a Health Canada regulatory perspective, the principal objective of
all forms of nutrition marketing is to aid consumers in making informed dietary choices to
reduce the risk of injury to health (33). However, others have argued that nutrition marketing is
9
yet another form of marketing by food companies driven by motives to increase sales rather than
benefit consumer health (34).
2.3.1.1. Nutrient content claims
Nutrient content claims are described by the FDR as “statements or expressions which describe,
directly or indirectly, the level of a nutrient or energy in a food or a group of foods” (10). The
FDR has defined a list of compliant nutrient content claim categories, such as dietary fibre
claims, and laid out a specific set of compositional requirements that must be met for each
specific claim within each category. For example, to make a “source of” claim regarding the
vitamin or mineral content of a food, the food must contain a minimum of 5% of the labelling
Daily Value (DV) of the vitamin or mineral. Some other examples of nutrient content claims
include “high in fibre”, “low in energy”, and “no added sugar” (10).
In this study, highly fortified foods were classified as foods containing added vitamins and
minerals in an amount that is greater than 25% of the DV for that vitamin or mineral. With the
exception of vitamin C, a nutrient content of at least 25% of the DV is the minimum amount
required to make an “excellent source of” nutrient content claim regarding a vitamin or mineral
in foods and beverages under Canadian regulations. Foods containing vitamin C require twice
that amount to make the same claim (10).
2.3.1.2. Health Claims
The FDR defines a health claim as “any representation in labelling or advertising that states,
suggests, or implies that a relationship exists between the consumption of a food and health”
(10). There are several different types of health claims and each type of claim has its own set of
regulations. The types of health claims include disease risk reduction claims (DRRC),
therapeutic claims, function claims, nutrient function claims, probiotic claims, general health
claims (32).
Disease risk reduction claims “link a food to a reduced risk of developing a diet-related disease
or condition in the context of the total diet” (10). There are currently five categories of disease
risk reduction claims that are permissible and the conditions to be met for making each
prescribed statement can be found in the Disease Risk Reduction Claims Table in the FDR (10).
10
A list of assessments for additional, more recently approved DRRCs, can be found on the Health
Canada website (35). An example of a disease risk reduction claim is: “A healthy diet rich in a
variety of vegetables and fruit may help reduce the risk of some types of cancer” (10). A
therapeutic claim relates to treating or alleviating a disease or health condition, or improving or
altering bodily functions (10). An example of a therapeutic claim is: “Oat fibre helps reduce
cholesterol” (10). Disease risk reduction claims and therapeutic claims are subject to pre-market
assessment by the Food Directorate of Health Canada (32). Only claims that have been
substantiated by rigorous scientific evidence are permitted. Details of the submission
requirements for substantiation of health claims have been published and updated regularly (36).
Function claims describe the effects that the consumption of a food has on regular body
functions (10). There are two subcategories of function claims: nutrient function claims and
probiotic claims (32). Nutrient function claims describe the role of energy or a particular nutrient
in a food in promoting normal body function or maintaining good health (10). An example of a
nutrient function claim is: “Protein helps build and repair body tissues” (10). Most nutrient
function claims require minimum amounts of the nutrient to be present, such as vitamin and
mineral nutrient function claims (10). However, some nutrient function claims, such as claims
relating to omega-3 or omega-6 fatty acids, do not require a minimum amount of nutrient to be
present in order to make the claim (10). However, in all cases, the amount of nutrient present in
the food must be stated in either the NFt or in a quantitative statement elsewhere on the food
label. Probiotic function claims are claims regarding the health benefits of microorganisms
present in a food and can be either strain-specific or non-strain-specific claims (32). Although
function claims must act in compliance with subsection 5.1 of the Canadian Food and Drugs Act
(FDA), which dictates that no claim shall be made that is “false, misleading, or deceptive” (37),
they do not require pre-market assessment by Health Canada (32). Instead, the Canadian Food
Inspection Agency has created the Industry Labelling Tool (32) to act as a reference to aid
industry in meeting certain scientific standards should they be asked by the CFIA to provide
evidence to substantiate a claim. In addition, Health Canada has published a Guidance Document
(38) to create guidelines on the addition of probiotics to food, such as setting a minimum amount
of probiotics that must be present in a food to make a probiotic function claim.
11
Finally, general health claims are defined as “broad claims that promote health through healthy
eating or that provide dietary guidance” (32). General health claims do not make reference to
health effects, diseases, or other health conditions. An example of a general health claim is a
weight maintenance claim, such as the following statement: “As part of healthy eating, this food
may assist in maintaining a healthy body weight because it is portion controlled” (10). Similar to
function claims, general health claims are not subject to pre-market assessment (32). Aside from
having to abide with subsection 5.1 of the FDA, which, as previously stated, dictates that no
claim may be “false, misleading, or deceptive” (37), general health claims do not fall under any
category-specific regulations. Industry is expected to follow guidelines provided by the CFIA
(32) in formulating general health claims.
2.3.1.3. Front-of-pack (FOP) labelling
In addition to nutrient content and health claims, front-of-pack (FOP) nutrition rating systems
and symbols are another form of nutrition marketing. FOP systems (FOPS) provide a snapshot of
the nutritional content and characteristics of a food or beverage, often consolidating different
dietary aspects of the food into a single visual representation (39). FOP labelling most often
appears on the principal display panel of a product, but may also appear on other panels (39).
The underlying purpose of most FOPS is to give consumers the ability to quickly compare foods
and make healthier choices (39).
Unlike nutrient content claims and health claims, FOP labelling is currently not subject to
specific regulations in Canada. Manufacturers may opt to pay an additional licensing fee to
display third-party FOP symbols or they may choose to create their own symbols (40). Some
examples of FOP systems created by industry are President’s Choice® Blue Menu® and Kraft®
Sensible Solutions™. Since there are currently no specific regulations in place restricting the use
of FOP systems and symbols on prepackaged foods in Canada, there are no standardized
nutrition criteria that are used to assess whether or not a food may include FOP labelling. As a
result, nutrition criteria vary widely and conflict between different FOP programs (39).
12
2.3.2. Influence of nutrition marketing on consumer attitudes
Recent studies in Canada have found that consumers form more positive attitudes—including
higher ratings of healthfulness and greater intent to purchase—towards prepackaged products
containing regulated nutrition-related claims (i.e. nutrient content claims or health claims) than
products that do not carry these claims (41, 42). In a 2013 study conducted in Canada (41), three
sodium claims—an approved disease risk reduction claim, a fictitious function claim, and an
approved nutrient content claim—were tested against a control claim (related to taste) in a mock
package experiment. Participants viewed each mock package and were given surveys to
complete to evaluate their attitudes toward the product. The mock package in each condition had
identical nutrient profiles and participants were provided with a Nutrition Facts table to view the
accurate nutritional information for each package. Results found that all three sodium claim
conditions—regardless of the type of claim—resulted in consumers having more positive
attitudes towards the product, and giving higher ratings of overall healthfulness and having
greater intent to purchase the product than the control condition.
Outside of Canada, studies have found variable results on the effects of nutrition marketing on
the attitudes of consumers. Generally, however, studies from Europe and the US have found that
consumers view nutrient content and health claims as useful and that consumers have more
positive attitudes towards the nutritional value of a food if it features a nutrient content or health
claim (43-46). It has also been found that the presence of a health claim on a product can result
in a general “halo” effect, causing the consumer to favourably view other nutritional attributes of
the food that are unrelated to the health claim (42). However, certain studies, such as a review
conducted by the European Food Information Council, have found that the overall attitude of
consumers towards a product may not necessarily improve with the addition of a health claim,
but may also depend on various factors such as food category and consumer variables, such as
familiarity with the claim and nutrition knowledge (42, 47).
In the case of FOP labelling, since there is currently no standardized FOP system and there are a
wide range of FOP systems, comparisons cannot be made between every potential FOP system
and all the other systems. However, studies have suggested that consumers tend to view products
with certain types of FOPS as being healthier than products that lack these systems (48-50). For
example, in a US study conducted in 2011 (50), a mock-package carrying a FOP system (i.e.
13
Smart Choices) was tested against a control mock-package carrying no FOP label. The mock-
package product used in both conditions in this study was a product that met the nutritional
criteria for carrying the Smart Choices icon, yet contained high amounts (i.e. 20% of the Daily
Value) of sodium and cholesterol. Study participants were given surveys to rate the overall
healthfulness of products, amongst other measures. Participants gave the mock-package carrying
the Smart Choices icon a significantly higher overall healthfulness rating and perceived the
product as having a significantly lower amount of sodium than the control mock-package with no
FOP icon. These types of findings suggest that consumers may prefer products carrying FOP
marketing as opposed to products lacking these systems.
2.3.3. Prevalence of nutrition marketing on prepackaged foods with added nutrients
A cross-sectional analysis conducted on a 2010 food database containing over 10,000
prepackaged foods sold in supermarkets in Canada found that 48.1% of food packages carry
some form of nutrition marketing (51). The most common type of claim was nutrient content
claims, followed by FOP labelling. Disease risk reduction claims were the least prevalent type of
claim, with only 1.7% of products carrying these claims. There has been some research
examining the marketing on the labels of energy drinks and other enhanced beverages sold in
Canada, finding that these beverages carried traditional forms of marketing, such as source and
function claims, in addition to claims highlighting physical performance and mental well-being
(29). However, there has been little research examining the nutrition marketing that occurs on
other nutritionally-enhanced foods such as voluntarily fortified, functional, and other
supplemented foods, and how the amount of marketing on these foods compares to general
foods.
2.4 Nutrient profiling of nutritionally-enhanced foods
2.4.1 What is nutrient profiling?
Nutrient profiling is defined as “the science of classifying or ranking foods according to their
nutritional composition for reasons related to preventing disease and promoting health” (1) and is
commonly used to define foods as ‘healthy’ or ‘unhealthy’ based on the levels of a variety of
14
nutrients in the food (52). Nutrient profiling is one method of evaluating the nutritional quality of
food products and is used in many nutrition policy applications worldwide, including the
regulation of front-of-pack labelling, health and nutrition claims, consumer education, and
restricting the marketing of less healthy foods to children and adolescents (1, 53). There is a
large selection of nutrient-profiling models that have been developed for different applications
by various organizations around the world. The model that was used in this research to evaluate
the healthfulness of foods with added nutrients is the Nutrient Profiling Scoring Criterion
(NPSC) created by Food Standards Australia New Zealand (FSANZ).
2.4.2 FSANZ Nutrient Profiling Scoring Criterion (NPSC)
In January, 2013, Standard 1.2.7 of the Australia New Zealand Food Standards Code was
introduced to govern the regulations of nutrition and health claims on food labels for all foods
sold in Australia and New Zealand (54). FSANZ constructed the Nutrient Profiling Scoring
Criterion (NPSC) system to evaluate an individual food’s healthfulness and eligibility to carry a
claim. In this research, the NPSC was used to compare scores between supplemented and
fortified foods with non-supplemented and non-fortified foods, to determine if there are any
significant differences in the healthfulness of one type of food over the other. The FSANZ model
has several advantages and was therefore chosen as the best model over other nutrient profiling
models for application in this research. First, the FSANZ model is a modified version of the
highly validated Ofcom model (55).The Ofcom model was originally developed by the UK Food
Standards Agency to restrict the advertising of food and drink products to children and has been
rigorously tested, validated, and adapted for various applications around the world (56).
Secondly, the FSANZ model itself has been through numerous stages of development, public
consultations and assessments, and has been tested and validated on over 10,000 foods and
beverages in Australia and New Zealand (1, 57). Third, one of the reasons the FSANZ model
was chosen over the original Ofcom model is that the FSANZ model contains an additional score
threshold for a new food category which includes cheese, edible oils, edible oil spreads, butter
and margarine, foods which were disqualified and not included in the Ofcom model. Since there
are supplemented and functional foods in these food categories, excluding them from the present
analyses would make the analysis in this research less comprehensive. Finally, the UK Ofcom
15
model calculates scores based on per 100 g values on food products, whereas the FSANZ model
uses either per 100 g or per 100 mL values—whichever is declared on the nutrition information
panel—as the basis of its score calculation. Many foods in the database used in this research—
the University of Toronto Food Label Information Program (FLIP)—are declared in volume (i.e.
mL values) on the Canadian nutrition facts tables (NFt) and would not have been easily
converted to gram values. Therefore, for these numerous reasons, the FSANZ model was deemed
to be the most appropriate and efficient model to use as the basis for evaluating the ‘healthiness’
of foods in this research.
2.4.2.1. Overview of FSANZ Nutrient Profiling Model (NPSC)
In the FSANZ nutrient profiling model (NPSC), each food or drink product is allocated into one
of three categories: beverages (Category 1); cheese, edible oil, edible oil spreads, butter and
margarine (Category 3); any food other than those included in categories 1 and 3 (Category 2).
Points are then added towards or deducted for each item according to nutrient content thresholds
for each category. Baseline points are added for nutrients that are associated with a risk of
chronic disease—energy content (kJ), saturated fat (g), total sugars (g) and sodium (mg). Points
are then deducted from the baseline points based on the fruit/vegetable/nut/legume (V), protein
(P) and fibre (F) content of the food. Thus, the final score is calculated with the following
formula:
𝐹𝑖𝑛𝑎𝑙 𝑠𝑐𝑜𝑟𝑒 = 𝑏𝑎𝑠𝑒𝑙𝑖𝑛𝑒 𝑝𝑜𝑖𝑛𝑡𝑠 – (𝑉 𝑝𝑜𝑖𝑛𝑡𝑠) – (𝑃 𝑝𝑜𝑖𝑛𝑡𝑠) – (𝐹 𝑝𝑜𝑖𝑛𝑡𝑠)
Scores fall on a scale between -18 to 81. Food items with lower scores are indicated as being
‘healthier’ than food items with higher scores.
All nutrient content values required to calculate a NPSC score, except for
fruit/vegetable/nut/legume (FVNL) content, are available in the Canadian NFt.
According to the NPSC, a product receives V points depending on the percentage of non-
concentrated and concentrated FVNL the product contains. For products containing only non-
concentrated FVNL, products containing 100%, greater than 80%, greater than 60%, greater than
16
40%, or equal to or less than 40% non-concentrated FVNL receive 8, 5, 2, 1, or 0 points
respectively. For products containing only concentrated FVNL, products containing 100%, at
least 67%, at least 43%, at least 25%, or less than 25% concentrated FVNL receive 8, 5, 2, 1, or
0 points respectively. Products containing a mixture of concentrate and non-concentrated FVNL,
the total percentage of FVNL in the product is calculated according to the following formula:
(% 𝑛𝑜𝑛 − 𝑐𝑜𝑛𝑐𝑒𝑛𝑡𝑟𝑎𝑡𝑒𝑑 𝑓𝑣𝑛𝑙) + (2 𝑥 % 𝑐𝑜𝑛𝑐𝑒𝑛𝑡𝑟𝑎𝑡𝑒𝑑 𝑓𝑟𝑢𝑖𝑡 𝑜𝑟 𝑣𝑒𝑔𝑒𝑡𝑎𝑏𝑙𝑒𝑠)
(% 𝑛𝑜𝑛 − 𝑐𝑜𝑛𝑐𝑒𝑛𝑡𝑟𝑎𝑡𝑒𝑑 𝑓𝑣𝑛𝑙) + (2 𝑥 % 𝑐𝑜𝑛𝑐𝑒𝑛𝑡𝑟𝑎𝑡𝑒𝑑 𝑓𝑟𝑢𝑖𝑡 𝑜𝑟 𝑣𝑒𝑔𝑒𝑡𝑎𝑏𝑙𝑒𝑠) + (% 𝑛𝑜𝑛 𝑓𝑣𝑛𝑙 𝑖𝑛𝑔𝑟𝑒𝑑𝑖𝑒𝑛𝑡) ×
100
1
As quantitative declarations of the quantity of food ingredients are not required to be labelled in
Canada, an in-house algorithm created by members of the L’Abbé Lab at the University of
Toronto was used to calculate the FVNL content of a food based on the position of an ingredient
in the Ingredients List. A summary flowchart of this algorithm can be found in Appendix 1.
Ingredients in the Ingredients List are listed by weight in descending over. Separate sets of
criteria were used depending on if a product contained non-concentrated FVNL or concentrated
FVNL.
Products containing only non-concentrated FVNL
To score at least 1 point, a FVNL must contribute greater than 40% to the total weight of the
product. A FVNL listed as the third ingredient in a product could account for, at most, one third
of the product’s weight (33%), assuming there are only three ingredients in the product and that
their weight is evenly distributed. Even in these unlikely circumstances, 33% falls below the
threshold of >40% required to score 1 point. Therefore, to score at least 1 point, a FVNL must be
one of the first two ingredients listed.
A product is allotted 2 points, and assumed to have a FVNL content of >60%, if a FVNL is listed
as the first ingredient, but there are other ingredients present that substantially contribute to the
product’s weight. A product receives 5 points and is assumed to have a FVNL content >80% if a
FVNL is listed as the first ingredient and other non-FVNL ingredients listed contribute only
minimal weight, such as preservatives, colour, vitamins, or minerals. A product receives 8
points, and is assumed to contain 100% FVNL, only if all of the ingredients in the product are
FVNL.
17
Products containing only concentrated FVNL
A FVNL must contribute ≥ 25% to the total weight for product to score 1 point. If a FVNL is
listed as the fourth ingredient in a product, the greatest possible weight it could account for is one
fourth of the total weight (25%), assuming the product contains only four ingredients and that the
weight of each ingredient is evenly distributed. Since such a circumstance is highly improbable,
it is assumed that a FVNL listed as the fourth ingredient will most likely contribute less than
25% to the total weight of the product. Therefore, to score at least one point, a FVNL must be
one of the first three ingredients listed.
A product is given 2 points, and assumed to contain ≥ 43% FVNL, if a FVNL is the first or
second ingredient but the non-FVNL ingredients in the product contribute substantially to the
weight. A product is allotted 5 points, and assumed to contain ≥ 67% FVNL, if a FVNL is the
first ingredient or if FVNL are the only ingredients in the product that substantially contribute to
the weight. A product receives 8 points and is assumed to contain 100% FVNL if it consists of
only FVNL ingredients. If a product contains a mix of concentrated and non-concentrated
FVNL, the criteria for non-concentrated FVNL is used.
2.4.3 The nutritional quality of nutritionally-enhanced foods
There is very little data examining the overall nutritional quality, including the saturated fat,
sugar, and sodium content, of foods with added nutrients. One study conducted in Ireland found
that nutrient profiles of voluntarily fortified foods were generally satisfactory, containing higher
levels of dietary fibre and lower levels of fat and saturated fat relative to energy content (24).
However, aside from this particular study, no other studies were found that directly assessed the
overall nutrient profiles of voluntarily fortified foods, supplemented foods, or functional foods.
Other studies have examined the association between fortified food consumption and the intake
of other nutrients. A study conducted in Ireland found that an increased consumption of fortified
foods in adults was associated with lower intakes of total fat and higher intakes of total
carbohydrates, total sugars and starch (58), and studies in France have found an association
between fortified breakfast cereals consumption and the replacement of energy from fats with
energy from carbohydrates in adults (59, 60) and children (60).
18
2.5 Concerns surrounding nutritionally-enhanced foods
Researchers have several concerns surrounding the expanding market of nutritionally-enhanced
foods. The growing popularity of foods with added nutrients has largely been attributed to an
increase in health-consciousness and the wish by consumers to purse a healthier lifestyle to
improve physical and psychological well-being (61, 62). However, there is speculation regarding
the benefits to health that the consumption of such foods are presumed to provide (63), and
concerns that the inappropriate use of nutritionally-enhanced foods may have negative effects on
population health.
Health professionals are wary that the consumption of foods with added vitamins and minerals,
especially in combination with supplement use, may result in high intakes of certain nutrients
that exceed tolerable upper intake levels and/or are not appropriate for certain age or gender
groups (5). The maximum levels of addition for micronutrients to fortified foods in Canada are
based on the highest Recommended Daily Allowances (RDAs)—or Adequate Intakes (AIs) if the
RDA is not available for a particular nutrient—and Tolerable Upper Levels (ULs) of individuals
within a population, in most cases the values indicated for males 19 years of age and older (64).
However, voluntarily fortified foods, such as breakfast cereals, are usually marketed towards all
members of a family, including children (23). This method represents a potential problem, as
setting maximum levels for the addition of vitamins and minerals to foods based on the age
group with the highest requirement level may result in unnecessarily high micronutrient intakes
in certain population subgroups, such as children (23).
In the case of supplemented foods, such as energy drinks and other nutrient-enhanced beverages,
a different approach has been used to set maximum levels of addition for micronutrients, since
these foods tend to contain much higher levels of added micronutrients that voluntarily-fortified
foods. Maximum levels were set based on data on the 95th percentile of daily dietary intake in the
general population, retrieved from the 2004 Canadian Community Health Survey Cycle 2.2, and
the estimated intake from supplements, determined from the highest levels of micronutrients
found in the five leading multivitamin and mineral supplements in Canada (65). Products that
contain micronutrients that are above the ULs for members of the general population, including
children, but below the UL for adults must carry a cautionary statement “For adults only.”
19
However, there is still concern that children and adolescents may be consuming these products,
since supplemented foods currently lack a product identifier and are easily accessible and sold on
the same shelves as other conventional foods in supermarkets. Health professionals have
suggested that there be no “adults only” category and that the levels of nutrients in all
supplemented foods should be safe for consumption for the general population (5). In addition,
certain nutrients, such as biotin and vitamin B12, do not have maximum levels of addition due to
a lack of defined ULs for these nutrients. Even though the literature has not yet produced
sufficient data to set ULs for these nutrients, this does not imply that there is no potential risk of
consuming these nutrients in any amount and caution should be exercised surrounding the levels
of these nutrients that manufacturers are adding to foods (65). There is also concern that many
functional foods contain herbal, bioactive, and novel ingredients, such as ginseng, that have a
limited history of safe use as a food, and that there is insufficient evidence to suggest that the
intake of such substances provide any real benefit to health (5, 63).
Another potential worry is that nutrients, such as vitamins, minerals and functional food
ingredients, will be added to foods that otherwise have poor nutritional value and will result in
higher intakes of nutrients, such as sodium and sugar, that may be detrimental to health (5).
Studies conducted in Europe have found that individuals with increased consumption of fortified
foods had lower intakes of total fats and higher intakes of carbohydrates—including higher
intakes of total sugars (58-60). The health effects of such an association remain unclear.
Although dietary guidelines have advised against too much fat in the diet (66) based on the view
that fats—particularly saturated fats—are a contributor to cardiovascular diseases (67), the
association between the two has recently become a controversial topic (67, 68). Furthermore, the
implications of replacing fats in the diet with carbohydrates remains uncertain. Researchers have
now suggested that substituting fats with certain types of carbohydrates, such as refined starches
and added sugars, provides no benefit to heart disease risk and may be detrimental to health (69,
70).
In addition, studies in Canada have investigated consumer response to the addition of nutrients to
foods. A Canada-wide survey conducted by the Dairy Farmers of Canada found that the majority
of adults and teens would increase their consumption of foods with poor nutritional value, such
20
as soft drinks, salty snacks, and fruit-flavoured drinks, if they were fortified, and that adults
would be more likely to feed their children these types of foods (71). In addition, focus groups
held across seven Canadian cities in 2004 revealed that consumers viewed the addition of
vitamins and minerals to foods of low nutritional value as an added bonus (72). The addition of
nutrients to otherwise ‘unhealthy’ foods is of even greater concern if heavy marketing on the
labels of such foods cause consumers to overlook levels of other nutrients, such as sugar and
sodium, and potentially lead to a shift in dietary patterns and displacement of healthy foods.
Studies have found that health claims have a positive effect on consumer attitudes (41-43, 46),
especially if they appear on certain products that are generally perceived as less ‘healthy’, such
as candies and spreads, as opposed to products that have already have a ‘healthy’ image, such as
yogurt and juices (47). Additionally, a conjoint study examining Danish, Finnish, and American
consumers’ perceptions of functional foods found that health claims appearing on functional
food labels had a positive effect on the perceived healthiness of these products, and that the
enrichment of ‘unhealthy’ foods, such as spreads, with bioactives, was perceived more positively
compared to the enrichment of ‘healthy’ foods, such as yogurt, with these substances (73). The
combined effects of adding vitamins, minerals, and substances to foods of low nutritional value
and heavy marketing on these products could have significant negative impacts on the dietary
patterns of Canadians.
2.6 Scope and objectives of thesis
The increasing popularity of foods with added nutrients have made researchers and health
professionals wary of the potential negative impacts of these foods on population health, such as
excessive nutrient intakes in certain population subgroups; the addition of micronutrients to
foods that otherwise have poor nutritional value; and excessive marketing of enhanced foods
causing consumers to overlook the levels of other nutrients, such as saturated fat and sugar (5).
However, the validity of these concerns cannot be judged at this time, as there is currently a lack
of data regarding nutritionally-enhanced foods in the Canadian marketplace. This thesis was
designed to conduct a comprehensive analysis on nutritionally-enhanced foods in Canada by
investigating the prevalence and nature of supplemented foods, functional foods, and foods with
high levels of voluntary fortification in the Canadian food market and the level of marketing on
such foods.
21
Study 1: The prevalence, nutritional quality, and marketing of supplemented foods
and functional foods in the Canadian marketplace
Objectives: This study aimed to: i) investigate the overall prevalence of supplemented foods
(SFs) and functional foods (FFs) using the University of Toronto Food Label Information
Program (FLIP) 2013 database; ii) identify the food categories containing the greatest
proportions of SFs and FFs; iii) determine the amount and types of added ingredients found in
SFs and FFs; iv) analyze the nutritional quality of SFs and FFs in the FLIP 2013 using the
validated Food Standards Australia New Zealand (FSANZ) nutrient profiling model (NPSC);
and v) quantify the occurrence of nutrition-related marketing, including nutrient content and
health claims, and FOP marketing, on the food labels of SFs and FFs. Hypothesis: It was
hypothesized that SFs and FFs would largely occur in food categories containing less healthy
products, such as cookies and high sugar beverages, and that the levels of added ingredients in
many products would be excessive and/or above Upper Levels (ULs). It was also hypothesized
that SFs and FFs in many food categories would be considered as ‘less healthy’ foods, and that
there would be high levels of marketing present on the food labels of SFs and FFs in these
categories compared to similar conventional foods.
Study 2: The nature and prevalence of voluntarily-fortified foods in the Canadian
marketplace
Objective: The objectives of this study were to: i) investigate the prevalence of voluntarily
fortified foods with high levels of added vitamins and minerals (VHVM) in the FLIP 2013; ii)
determine the nutritional quality of these foods using the validated FSANZ nutrient profiling
model; and iii) measure the level of marketing occurring on the packaging of these products.
Hypothesis: It was hypothesized that a large proportion of foods with high levels of voluntary
fortification would occur in food categories that are generally considered to be less healthy
foods, i.e. foods to be limited, according to Canada’s Food Guide guidance. It was also
hypothesized that many of these products would be considered ‘less healthy’ using the NPSC
model and contain high levels of food label marketing.
22
Chapter 3
3 - Study 1: The prevalence, nutritional quality, and marketing
characteristics of supplemented foods and functional foods in
the Canadian marketplace
Student’s contribution:
The original collection of food information in the FLIP 2013 database was previously conducted
by Alyssa Schermel (BSc. MSc.) and other members of the L’Abbé Lab before I began my MSc
thesis. However, I conducted all the research in this thesis related to SFs, FFs, and VHVMs using
the information provided in the FLIP 2013 database. In addition, I validated the marketing
information of foods in several food categories in the FLIP 2013 after the initial collection was
complete.
23
3.1 Abstract
Supplemented foods (SFs) and functional foods (FFs) (i.e. foods with high levels of vitamins,
minerals, bioactives, and other substances) have been entering the Canadian market and are a fast
growing sector of the food industry. Health professionals are wary that the consumption of these
foods may have negative implications on population health, such as leading to excessive nutrient
intakes that exceed Upper Levels (ULs) and/or are not appropriate for certain population
subgroups (5). The objective of the present study was to help fill gaps in knowledge surrounding
the prevalence and nature of SFs and FFs in the Canadian marketplace. Between May and
September 2013, information was collected from prepackaged foods carrying a Nutrition Facts
table (NFt) (n = 15,401) from 4 major grocery store chains across Canada: Loblaws, Metro,
Sobeys, and Safeway. Information from the NFt, Ingredients List, and marketing information—
such as health claims and front-of-pack (FOP) systems—was used to classify foods and
determine the type and/or amount of added ingredients present in each food. Less than 3% of
total foods collected in the FLIP 2013 were classified as SFs (n = 52) and FFs (326). The types
of foods most likely to be supplemented were certain types of beverages and fruit juices. FFs
were most commonly found in bakery products (e.g. grain-based bars), dairy products and
substitutes (e.g. yogurts), and cereals and other grain products (e.g. breakfast cereals). The most
frequently added supplemented ingredients were vitamin B6 (n = 20) and vitamin B12 (n = 15),
and the most common functional ingredients were inulin (n = 134) and probiotics (n = 85).
Although several SFs (n = 13) contained at least one vitamin/mineral that exceeded RDAs or
AIs, only 2 SFs contained a vitamin/mineral that exceeded the UL. This study provides baseline
data on SFs and FFs and can be used to design future studies investigating the consumption of
these foods by the Canadian population.
3.2 Introduction
Traditionally, the addition of nutrients to foods has been strictly regulated in Canada—permitted
only for purposes such as preventing or correcting nutrient deficiencies in the population,
restoring nutrients lost in the manufacturing process, addition to special purpose foods such as
infant formulas, and ensuring the nutritional equivalence of substitute foods (9). Recently,
however, foods with high levels of added nutrients, such as vitamins, minerals, amino acids,
24
bioactives and other substances, have gained market access and are a fast-growing sector of the
food industry (16, 26). Depending on the type and amount of nutrients added, these foods may be
referred to as supplemented foods (SFs) or functional foods (FFs).
Supplemented foods refer to nutritionally-enhanced foods containing high levels of added
vitamins, minerals, amino acids, or caffeine that do not comply with traditional fortification and
enrichment policies. To bypass the restrictive policies imposed under the food regulatory
framework, many SFs were previously classified as Natural Health Products (NHPs). However,
as the introduction of food-like NHPs began to flourish, Health Canada realized that many of
these products would be more appropriately classified under the Food and Drug Regulations
(FDR) as foods, as they were being packaged, marketed, and consumed as conventional foods
rather than drugs (16). Between 2010 and 2012, a process was undertaken to transition several
hundred products from the Natural Health Products Regulations (NHPR) to the food regulatory
framework, and rename them as supplemented foods (19). Despite their noncompliance with
food regulations, Health Canada permitted SFs that do not pose any immediate health risks to be
sold through the issuance of Temporary Marketing Authorization Letters (TMALs). Foods
carrying TMALs are temporarily granted market access for either 2-year or 5-year periods,
during which time manufacturers have to provide Health Canada with data to address
information gaps or reformulate their products to meet restrictions set by the FDR to continue
their sale (17). In addition to SFs, foods containing added ingredients that are associated with
providing a physiological benefit and/or reducing the risk of chronic disease—such as novel
fibres, protein isolates and concentrates, pro and prebiotics, and omega-3 and omega-6 fatty
acids—have been gaining popularity in the market. Health Canada refers to these foods as
‘functional foods’ (21). The term ‘functional food’ is used in a general sense, in that there is
currently no regulatory definition a food must follow or list of ingredients that a food must
contain to be deemed ‘functional’.
A series of guidance documents have been published by Health Canada (18-20, 38) to provide
food manufacturers with information on how supplemented and functional foods may be
formulated, including minimum and maximum levels for the addition of certain nutrients, such
as caffeine. However, to date, there is no separate regulatory framework or product identifier to
25
distinguish supplemented and functional foods from other conventional foods. As a result,
consumer confusion may arise surrounding the appropriate use of these foods within the context
of a healthy, balanced diet. Researchers and health professionals are concerned that the
consumption of nutritionally-enhanced foods may inadvertently have detrimental effects on
population health, such as resulting in high intakes of certain nutrients that exceed upper levels
(ULs) and/or are not suitable for certain age groups, and the overconsumption of substances,
such as herbals and bioactives, that have a limited history of safe use as a food (5). Additionally,
there are concerns that the addition of vitamins, minerals, and other nutrients to foods of
otherwise low nutritional value, such as sugary beverages and salty snacks, may negatively
impact the dietary patterns of Canadians and lead to the displacement of healthy foods (5, 71).
Despite these concerns, there has been no research examining SFs and FFs in Canada. Thus the
objective of this research was to evaluate the prevalence and nature of supplemented and
functional foods in the Canadian food supply. In Part I of this study, the frequency of SFs and
FFs, as well as the type and amount of ingredients added to these foods, was determined. In Part
II of this study, the nutritional quality and nutrition-related marketing of SFs and FFs was
analyzed.
.
3.3 Methodology
3.3.1 Data collection
Food Label Information Program (FLIP)
The University of Toronto Food Label Information Program (FLIP) 2013 is a database of food
package label information of foods sold in Canada. The FLIP 2013 contains nutrition
information on 15,401 prepackaged products collected between May and September 2013 from
the top four supermarket chains of Canada—Loblaws, Metro, Sobeys, and Safeway—and
represents 75.4% of the grocery retail marketshare (74). Complete information on the data
collection and processing of the FLIP 2013 can be found elsewhere (75).
Ten products were removed from the initial collection due to manufacturer labelling errors (e.g.
inconsistent validation by Atwater factors). Additionally, meal replacements, products intended
for children under the age of 4, and products lacking a standard Canadian NFt (e.g. Natural
26
Health Products) were also excluded from the present analysis, leaving a total of 15,332 product
in the final sample that was used for this study.
3.3.2 Data analysis
To distinguish nutritionally-enhanced foods, products containing any of the following types of
nutrients as an ingredient were included: vitamins, minerals, herbals, bioactives, protein
isolates/concentrates, amino acids, omega-3 fatty acids, omega-6 fatty acids, and novel food
ingredients. A complete list of these ingredients can be found in Appendix 2. Foods and
beverages that contained added nutrients due to fortification, enrichment, or food additive
purposes that are in compliance with the FDR were then excluded from these analyses.
Remaining products were categorized into two groups.
Supplemented foods
At the time that these analyses were conducted, Health Canada had not yet finalized its definition
of a supplemented food. Therefore, for the purpose of this study, SFs were defined as foods that
contain added vitamins, minerals, amino acids, or caffeine, as indicated in the Ingredients List,
added in amounts other than that which is permissible by the current FDR for fortification or
enrichment purposes.
Functional foods
Health Canada has defined a functional food as a food that “is similar in appearance to, or may
be, a conventional food, is consumed as part of a usual diet, and is demonstrated to have
physiological benefits and/or reduce the risk of chronic disease beyond basic nutritional
functions” (21). However, there is currently no strict list of ingredients that are deemed to be
considered ‘functional’. For the purpose of this study, foods that contained added nutrients other
than vitamins and minerals and made some indication, in the form of claims or other statements,
that they contained these added substances for the purpose of providing a health benefit were
categorized as functional foods. Foods that contained a functional ingredient but did not make
any claim or statement regarding its intended physiological benefit were excluded, since in such
cases, manufacturers may have added these substances to foods for other purposes (e.g. acacia
gum added as a food additive).
27
3.3.2.1. Part I: Characterizing the frequency of SFs and FFs, and the amount and type of
ingredients added
Foods in the FLIP 2013 were categorized into major and subcategories based on Schedule M of
the FDR (76). Since each major food category contains a wide range of food types, the frequency
of SFs and FFs was determined at the food subcategory level.
The amount of vitamin, mineral, or amino acid present in a SF was calculated using percent
Daily Values provided in the NFt (64) and analyzed per stated serving size. The resultant levels
were then compared to the highest Recommended Dietary Allowances (RDAs)—or Adequate
Intakes (AIs) if RDAs were not available—and Upper Limits (ULs) of children and adolescents
(4-13 years) and adults (19 years and older) within the population, excluding pregnant and
lactating women, and individuals over the age of 70 (77).
The amount of functional ingredient added to a food could not be determined from the
information provided in the NFt or Ingredients List and therefore was not calculated. However,
the type of functional ingredients added were characterized as: herbals/bioactives, novel fibres,
omega-3/omega-6 fatty acids, protein concentrates/isolates, and other novel ingredients.
3.3.2.2. Part II: Determining the nutritional quality and level of marketing of SFs and FFs
The Nutrient Profiling Scoring Criterion (NPSC) created by Food Standards Australia New
Zealand (FSANZ) (54) was used to determine the nutritional quality of foods in the FLIP 2013.
The NPSC is a validated nutrient profiling model that uses a points-based system to determine
the healthiness of a food (57). Foods are first classified into one of three categories. Category 1
foods consist of beverages; Category 3 foods consist of cheese, edible oil spreads, butter, and
margarine; and Category 2 foods consist of remaining foods that are not included in either of the
other categories. Each food obtains a score based on category-specific nutrient thresholds. Points
are added for energy content and nutrients that that have been associated with an increased risk
of chronic disease—saturated fat, total sugars, and sodium—and points are deducted for nutrients
that are thought to be beneficial to health—fibre, protein, and fruit/vegetable/nut/legume content.
In this system, the lower the score, the ‘healthier’ the food. Scores range from -18 to 81.
Category 1, 2, and 3 foods are permitted to carry health claims in Australia and New Zealand
only if they receive final scores less than 1, 4, or 28, respectively. Foods scoring less than these
28
cut points were rated ‘healthy’ and foods scoring above these cut points were rated ‘less healthy’.
Further details of the FSANZ nutrient-profiling methodology (NPSC) can be found in Appendix
4.
NPSC scores were calculated for all foods in the FLIP 2013 database and medians were
compared between SFs and non-SFs and between FFs and non-FFs within each food
subcategory. Median final scores were also examined to determine if these nutritionally-
enhanced foods would be considered ‘healthy’ enough to be permitted to carry health claims
under the FSANZ NPSC system. In the case of FFs, it was anticipated that certain added
ingredients (i.e. novel fibres and protein isolates/concentrates) may have contributed to final
NPSC scores, as points are allotted based on the fibre and protein content of foods. Therefore, to
determine the extent to which functional ingredients in FFs altered final NPSC scores, points
received or deducted for each nutrient contributing to the final score were determined in food
subcategories containing large proportions (>20%) of FFs containing added novel fibres or added
protein isolates/concentrates.
Nutrition-related marketing present on the food labels of products in the FLIP 2013 were
classified as nutrient content claims, health claims, and various front-of-pack (FOP)
systems/symbols, according to the Canadian FDR (as described previously). In the present study,
each individual claim or FOP system/symbol was calculated as one marketing item. Repeats of
the same marketing item on different panels of a food package were not included as separate
marketing items. Marketing items were categorized as either government regulated claims (i.e.
nutrient content and health claims) or claims that lack specific regulations (i.e. FOP
symbols/systems (FOPS)). The amount of regulated claims, FOPS, and total marketing was
compared between SFs and non-SFs, and between FFs and non-FFs. Statements that appeared on
a product but were not related to nutrition (e.g. statements regarding taste) were not included as
claims.
3.3.2.3 Statistical Analyses
Statistical analyses were conducted using SAS version 9.3 (Statistical Analysis Software Co,
Cary NC). Categorical data were presented as frequencies and percentages. Continuous data
were presented as medians, Q1s, and Q3s. Only food subcategories containing at least 10 SFs or
10 FFs were included in nutritional quality and marketing analyses. The Wilcoxon signed rank
29
test was used to make comparisons in FSANZ NPSC scores and marketing items between SFs
and non SFs, and between FFs and non-FFs within each food subcategory. Chi squared tests
were used to make comparisons between groups in the proportion of products meeting ‘healthy’
cutpoints to be eligible to carry a health claim based on the FSANZ NPSC system. A P value of
<0.05 was considered significant.
3.4 Results
3.4.1 Part I: Characterizing the frequency of SFs and FFs, and the amount and type of
ingredients added
Supplemented Foods
A total of 52 foods and beverages (<1% total products) were classified as SFs (Appendix 3). The
most commonly added supplemented ingredients were vitamin B6 (n = 20), vitamin B12 (n =
15), and niacin/vitamin B1 (n = 13). Overall, 13 SFs contained at least one vitamin/mineral that
exceeded the Recommended Dietary Allowance (RDA) or AI (Adequate Intake).
The subcategories containing the greatest numbers of supplemented foods (Table 1) were
carbonated and non-carbonated beverages and wine coolers (n = 15, 6% of total foods in
subcategory), and juices, nectars, and fruit drink substitutes (n = 24, 4% of total foods in
subcategory). The only micronutrients added to SFs occurring in the juices, nectars, and fruit
drink substitutes subcategory were vitamins and/or minerals, with a median of 2 added per SF.
The most commonly added vitamins and minerals in this subcategory were calcium (n = 10),
vitamin D (n = 9), thiamine/vitamin B1 (n = 9), and folic acid (n = 7). None of the SFs in the
juices, nectars, and fruit drink substitutes subcategory contained added nutrients in amounts that
exceeded the RDA/AI or UL (Table 2).
In the carbonated, non-carbonated beverages and wine coolers subcategory—including energy
drinks—SFs contained a median of 5 added micronutrients, including vitamins and minerals,
amino acids and caffeine. The most commonly added vitamins and/or minerals in this
subcategory were vitamin B6 (n=14), vitamin B12 (n=11), niacin/vitamin B3 (n=11), and
pantothenic acid/vitamin B5 (n=11). The most commonly added vitamins also tended to be the
ones added in the highest amounts (Table 2). SFs in this category contained vitamin B6 (up to
7.0 mg), vitamin B12 (up to 12 µg), niacin/vitamin B1 (up to 39.1 mg), and pantothenic
30
acid/vitamin B5 (up to 20.3 mg) in amounts that exceeded the RDAs/AIs of both children and
adults; and 2 SFs contained niacin/vitamin B1 in an amount (39.1 mg) exceeding the ULs of both
children and adults. In addition to vitamins and minerals, a large proportion of supplemented
foods in this subcategory contained caffeine (61%) and the amino acid taurine (61%), and a
smaller proportion contained the amino acid L-theanine (11%) (Table 3). Although very high
levels of these nutrients were added, no SFs contained caffeine or amino acids in amounts
exceeding the maximum levels permitted for addition as set in the Guidance Documents for
Temporary Marketing Authorizations (TMAs)(18).
Functional foods
A total of 326 (2% of total foods) foods and beverages were classified as functional foods (Table
4). Major food categories containing the greatest numbers of functional foods were dairy
products and substitutes (n=102), bakery products (n=98), and cereals and other grain products
(n=76). Food subcategories containing the greatest proportions of foods that are functional
include shakes and shake substitutes (36%), grain-based bars, with filling or coating (31%),
yogurt (32%), ready-to-eat breakfast cereals, puffed and coated, without fruit or nuts (25%),
ready-to-eat breakfast cereals, fruit and nut type, granola, biscuit type cereals (18%), and grain-
based bars, without filling or coating (17%). Many of the same subcategories also contained the
greatest number of functional food products including: yogurt (n=74), grain-based bars, with
filling or coating (n=33), and ready-to-eat breakfast cereals, fruit and nut type, granola, biscuit
type cereals (n=30). The most commonly added types of functional ingredients were novel fibres
(n=191) and herbals/bioactives (n=109), with inulin (n=134) and probiotic bacterial cultures
(n=85) being the most commonly added ingredient in each category, respectively. A complete
list of functional ingredients added to foods in each major food category can be found in Table
5.
3.4.2 Part II: Determining the nutritional quality and level of marketing of SFs and FFs
Nutritional value of supplemented foods and functional foods
The median nutrient profiling scores of SFs in both food subcategories analyzed were within the
threshold (<1) to carry health claims using the FSANZ NPSC system, and in both food
31
subcategories, SFs did not have median NPSC scores that were higher (i.e. less healthy) than
non-SFs (Table 6). In the carbonated and non-carbonated beverages subcategory, there was no
statistical difference in median NPSC scores of SFs and non-SFs. Additionally, there was no
difference between SFs and non-SFs in this subcategory when comparing the proportions of
products that met cutpoints to be considered ‘healthy’ (Table 7). SFs in the juices, nectars, and
fruit drink substitutes subcategory, on the other hand, had significantly lower (i.e. more healthy)
NPSC scores and a greater proportion of products that met ‘healthy’ cutpoints compared to non-
SFs in the same subcategory.
The median NPSC scores of FFs in four out of ten subcategories analyzed were overall
‘healthier’ (i.e. lower) compared to non-FFs in these categories (Table 8). These subcategories
include: cookies and graham wafers, grain-based bars (with filling or coating), grain-based bars
(without filling or coating), and pastas without sauce. In order to understand the source of these
differences in NPSC scores, the final scores of products in these subcategories were broken
down into the NPSC score components (Table 10). The median points deducted for fibre content
in FFs were significantly greater than non-FFs in all four subcategories, suggesting that added
novel fibres in FFs somewhat contributed to the difference in final scores seen between FFs and
non-FFs. However, FFs in the cookies and graham wafers, grain-based bars (with filling or
coating), and grain-based bars (without filling or coating) subcategories also had significantly
lower points added for other nutritional components, such as energy and total sugars, compared
to non-FFs, suggesting that high fibre content was not the sole reason FFs in these subcategories
had overall healthier final scores compared to non-FFs. Despite FFs being overall ‘healthier’
than non-FFs in these three subcategories, the median NPSC scores of FFs were still too high
(i.e. not healthy enough) to be permitted to carry health claims using the FSANZ NPSC system
(Table 8). Additionally, there was no difference between FFs and non-FFs within two of these
subcategories—cookies and graham wafers, and grain-based bars (with filling or coating)—in
the proportion of products meeting ‘healthy’ cutpoints (Table 9).
There were no statistical differences in median NPSC scores between FFs and non-FFs in the
remaining food subcategories examined. These subcategories included: carbonated and non-
carbonated beverages and wine coolers; ready-to-eat breakfast cereals (puffed and coated,
without fruit or nuts, very high fibre); ready-to-eat breakfast cereals (fruit and nut type, granola,
32
biscuit type); plant-based beverages, milk, buttermilk, and milk-based drinks; yogurt; and juices,
nectars, and fruit drink substitutes. The distribution of points deducted or received per nutrient
varied according to food subcategory (Table 10). FFs in all but one of these subcategories—
ready-to-eat breakfast cereals (puffed and coated, without fruit or nuts, very high fibre)—were
deemed sufficiently ‘healthy’ to carry health claims.
The median NPSC scores of FFs were not significantly higher (i.e. less healthy) than non-FFs in
any of the subcategories analyzed.
Marketing on food labels of supplemented foods and functional foods
Regardless of the overall nutritional quality of the food, both SFs and FFs were more heavily
marketed than comparable foods that do not contain supplemental or functional ingredients
(Tables 11 and 12). The median number of total marketing items present on food labels was
statistically higher in SFs in comparison to non-SFs in both food subcategories examined. SFs in
both subcategories had a greater number of regulated claims (i.e. nutrient content and health
claims) than non-SFs. However, FOP marketing was greater on SFs in comparison to non-SFs
only in the juices, nectars, and fruit drink substitutes subcategory. There was no statistical
difference in FOPS between SFs and non-SFs in the carbonated and non-carbonated beverages
and wine coolers subcategory.
In all subcategories analyzed, FFs had significantly higher levels of nutrition marketing on food
labels than non-FFs (Table 12). In five subcategories, FFs had significantly higher levels of both
regulated claims and FOPS in comparison to non-FFs within each category. In two
subcategories—grain-based bars (without filling or coating); and ready-to-eat breakfast cereals
(fruit and nut type, granola, biscuit type)—there was no statistical difference in the number of
regulated claims between FFs and non-FFs. However, in these subcategories, FFs had
significantly greater numbers of FOPS than non-FFs. In two other subcategories—carbonated
and non-carbonated beverages and wine coolers; and yogurt—the opposite trend occurred, where
there was a significantly higher number of regulated claims appearing on the food labels of FFs
in comparison to non-FFs, but no statistical difference in the amount of FOP marketing between
these types of foods. In one subcategory (plant-based beverages, milk, buttermilk, and milk-
based drinks), there was no statistical difference in the level of marketing between FFs and non-
FFs when regulated claims and FOPS were examined separately.
33
Table 1. Prevalence of supplemented foods* (SFs) in the Canadian marketplace in 2013
Food category and subcategory Total
N
Supplemented foods
n (% of total foods)
Beverages
Carbonated and non-carbonated beverages
and wine coolers
268
15 (6)
Sports drinks and water
125 3 (2)
Coffee 29 1 (3)
Cereals and other grain products
Ready-to-eat breakfast cereals, puffed and
coated, without fruit or nuts, very high
fibre
77
1 (1)
Dairy products and substitutes
Cheese, including cream cheese and
cheese spread
453
2 (<1)
Plant-based beverages, milk, buttermilk
and milk-based drinks, such as chocolate
milk
247
2 (1)
Fruit and fruit juices
Juices, nectars and fruit drink substitutes
636
24 (4)
Vegetables
Vegetable juice and vegetable drink
43
4 (9)
* Supplemented foods were defined as foods that contain added vitamins, minerals, amino acids, or caffeine added in amounts
other than that which is permissible by the current FDR for fortification or enrichment purposes.
34
Table 2. Levels of added vitamins and minerals in the most common supplemented food*(SF) categories
Food
category¥
Micronutrient Number of SFs
containing nutrient
n (% of total
SFs/category)
RDA or AI
/UL
Median amount/
serving
Amount/serving (%DV)
Adult Child Min Max
Juices, nectars
and fruit drink
substitutes
Folic acid (µg)
7 (29)
400/1000
300/600
99
66 (30)
132 (60)
Riboflavin (mg) 2 (8) 1.3/ND 0.9/ND 0.1 0.1 (6) 0.1 (6)
Thiamine (mg) 9 (38) 1.2/ND 0.9/ND 0.2 0.1 (8) 0.2 (15)
Vitamin B6 (mg) 2 (8) 1.3/100 1.0/60 0.12 0.12 (6) 0.12 (6)
Vitamin D (IU) 9 (38) 600/4000 600/4000 100 16 (8) 120 (60)
Vitamin E (mg) 5 (21) 15/1000 11/600 2 2 (20) 2.5 (25)
Calcium (mg) 10 (42) 1000/2500 1300/3000 330 88 (8) 330 (30)
Iron (mg) 6 (25) 8/45 8/40 1.4 1.4 (10) 2.1 (15)
Magnesium (mg) 2 (8) 400/350 240/350 25 25 (10) 25 (10)
Potassium (mg) 4 (17) 4700/ND 4500/ND 297.5 245 (7) 385 (11)
Carbonated
and non-
carbonated
beverages and
wine coolers
Niacin (mg) 11 (61) 16/35 12/20 20.7 5.8 (25) 39.1 (170)
Pantothenic acid
(mg)
11 (61) 5/ND 4/ND 4.9 1.8 (25) 20.3 (290)
Vitamin B6 (mg) 15 (83) 1.3/100 1/60 4.0 0.5 (25) 7.0 (390)
Vitamin B12 (µg) 12 (67) 2.4/ND 1.8/ND 8.1 5 (250) 12 (600)
Vitamin C (mg) 2 (11) 90/2000 45/1200 78 100 (100) 160 (160)
Calcium (mg) 1 (6) 1000/2500 1300/3000 330 330 (30) 330 (30)
Zinc (mg) 4 (22) 11/40 8/23 0.9 0.9 (10) 3.6 (40)
* Supplemented foods were defined as foods that contain added vitamins, minerals, amino acids, or caffeine added in amounts other than that
which is permissible by the current FDR for fortification or enrichment purposes. ¥ Food subcategories containing at least 10 supplemented foods
35
are shown. RDAs, AIs, and ULs are based on the highest requirements in adults (excluding pregnant and lactating women, and individuals over
the age of 70) and children aged 4-13 (77). Adequate Intakes (AIs) are followed by Abbreviations – SF = supplemented food; RDA =
Recommended Dietary Allowance; AI = Adequate Intake; UL = Upper Limit; % DV = Percent Daily Value.
36
Table 3. Added caffeine and amino acids in supplemented foods* (SFs) in Canada in 2013
Food
category
Micronutrient Number of SFs
containing nutrient
n (% of total SFs)
Max. amount
permitted¥
Amount/serving
Median Min Max
Carbonated
and non-
carbonated
beverages
and wine
coolers
Taurine
(mg/serving)
11 (61) 3000 1000 200 2000
L-theanine
(mg/serving)
2 (11) 300 25 25 25
Caffeine
(ppm)
11 (61) 400 320 320 360
* Supplemented foods were defined as foods that contain added vitamins, minerals, amino acids, or
caffeine added in amounts other than that which is permissible by the current FDR for fortification or
enrichment purposes. ¥ Maximum levels of addition for caffeine and amino acids are set out in Guidance
Documents pertaining to products that have been issued TMAs (17, 18). Abbreviations – SF =
supplemented food.
37
Table 4. Prevalence of functional foods* (FFs) in the Canadian marketplace in 2013 by food
subcategory
Food category and subcategory
(n) total
products
Number of
FFs/category
(%)
Bakery products
Grain-based bars, with filling or coating
106 33 (31)
Grain-based bars, without filling or coating
100 17 (17)
Cookies and graham wafers 391 22 (6)
Bagels, tea biscuits, scones, rolls, buns, croissants, tortillas, soft bread
sticks, soft pretzels and corn bread
288 6 (2)
Crackers, hard bread sticks and melba toast
279 5 (2)
Bread, excluding sweet quick-type rolls 231 5 (2)
French toast, pancakes and waffles 59 4 (7)
Coffee cakes, doughnuts, danishes, sweet rolls, sweet quick-type
breads and muffins
123 4 (3)
Brownies 28 2 (7)
Beverages
Carbonated and non-carbonated beverages and wine coolers
268 14 (5)
Sports drinks and water
125 2 (2)
Coffee
29 1 (3)
Cereals and other grain products
Ready-to-eat breakfast cereals, fruit and nut type, granola, biscuit type
cereals
170 30 (18)
Pastas without sauce 439 23 (5)
Ready-to-eat breakfast cereals, puffed and coated, without fruit or nuts,
very high fibre
77 19 (25)
Hot breakfast cereals
107 4 (4)
38
Table 4. (continued)
Food category and subcategory
(n) total
products
Number of
FFs/category
(%)
Dairy products and substitutes
Yogurt 233 74 (32)
Plant-based beverages, milk, buttermilk and milk-based drinks 247 14 (6)
Quark, fresh cheese and fresh dairy desserts 99 6 (6)
Shakes and shake substitutes 11 4 (36)
Cheese, including cream cheese and cheese spread 453 4 (1)
Fruit and fruit juices
Juices, nectars and fruit drink substitutes 637 14 (2)
Vegetables
Vegetable juice and drink 43 2 (5)
Meat, poultry, their products and substitutes
Luncheon meats 101 1 (1)
Nuts and seeds
Peanut butter
50 1 (2)
Desserts
Dairy desserts, frozen (cakes, bars, sandwiches or cones) 187 2 (1)
Ice cream, ice milk, frozen yogurt and sherbet 395 1 (<1)
Fats and oils
Butter, margarine, shortening and lard 91 5 (6)
Dressings for salad 252 3 (1)
Marine and freshwater animals
Marine and fresh water animals without sauce 209 4 (2)
*Functional foods were defined as foods that contained substances (other than vitamins and minerals) added for the purpose of
providing a health benefit.
39
Table 5. Ingredients added to functional foods in the Canadian food market in 2013
*Functional foods were defined as foods that contained substances (other than vitamins and minerals) added for the purpose of
providing a health benefit. ¥ Major food categories containing at least 10 functional foods (FFs) are shown. ǂ Entries in
bold type represent categories of functional ingredients. Abbreviations – FF = functional food.
Number of FFs¥ containing ingredient per food category
N (% of total FFs in food category)
Ingredient Bakery
products
(n = 98)
Beverages
(n = 17)
Cereals and
other grains
(n = 76)
Dairy products
and substitutes
(n = 102)
Fruit and fruit
juices
(n = 14)
Novel fibres
Inulin 78 (80) 2 (12) 36 (47) 11 (11) 4 (29)
Corn bran 7 (7) - 14 (18) - -
Wheat bran 38 (39) - 25 (33) 1 (1) -
Oat bran 9 (9) - 2 (3) - -
Oat hull fibre - - 6 (8) - -
Beta-glucan 1 (1) - - - -
Acacia gum - - 1 (1) - 4 (29)
Polydextrose - - 1 (1) - -
Dextrin - - 1 (1) - 1 (7)
Psyllium seed husk - - 2 (3) - -
TOTAL: 92 (94) 2 (12) 74 (97) 11 (11) 8 (57)
Herbals/bioactives
Probiotic cultures 3 (3) - 2 (3) 79 (78) 1 (7)
Ginseng extract - 7 (41) - - -
Yerba mate extract - 1 (6) - - -
Milk thistle seed extract - 2 (12) - - -
Green tea extract 3 (3) 2 (24) 1 (1) - -
Guarana seed extract - 6 (35) - - -
Green coffee bean extract - 3 (18) - - -
Bee pollen - - 1 (1) - -
Maca root - - 1 (1) - -
Red wine extract 1 (1) - - - -
Rosemary extract - 1 (1) - -
TOTAL: 7 (7) 16 (94) 6 (8) 79 (78) 1 (7)
Omega-3/omega-6
DHA oil - - - 1 (1) -
Encapsulated fish oil - - - 4 (4) 2 (14)
Flaxseed oil - - - 11 (11) 1 (7)
TOTAL: - - - 15 (15) 3 (21)
Protein
concentrates/isolates
Soy protein 7 (7) - 6 (8) 1 (1) -
Whey protein 4 (4) 1 (6) - 4 (4) -
TOTAL: 11 (11) 1 (6) 6 (8) 4 (4) -
Other novel ingredients - - - - 3 (21)
Plant sterols - - - - 3 (21)
40
Table 6. Comparison of NPSC nutrient profile scores* of supplemented foods¥ (SFs) and non-
supplemented foods (non-SFs) in the Canadian marketplace in 2013
Food category
SFs (n)
Non-SFs
(n)
Median nutrient
profiling score
(Q1, Q3)ǂ
p-
value
Direction of
significanceѱ
SF Non-SF
Carbonated and
non-carbonated
beverages and
wine coolers
15
253
0 (-2, 2)
1 (0, 2)
0.52
NS
Juices, nectars
and fruit drink
substitutes
24
612
-2 (-3, 0)
0 (-2, 1)
0.02
Positive
* Nutrient profile scores are based on the FSANZ Nutrient Profiling Soring Criterion (NPSC). ¥ Supplemented
foods (SFs) were defined as foods containing added vitamins, minerals, amino acids, or caffeine added in
amounts beyond what is permissible for fortification/enrichment purposes according to the FDR. Food
subcategories containing at least 10 SFs were analyzed. ǂ Q1 and Q3 refer to 25% and 75% quartile median
values. ѱ A p-value < 0.05 was considered significant. Positive significance indicates that median scores of
SFs are significantly lower (or “healthier”) than median scores of non-SFs. NS indicates no significance.
Products meeting specific cut points (beverages: <1; cheese, edible oil, edible oil spreads, margarine, or butter:
<28; all other foods: <4) based on the NPSC system are considered ‘healthy’ and would be permitted to carry a
health claim in Australia/New Zealand.
41
Table 7. Number and proportion of SFs* and non-SFs meeting ‘healthy’ cutpoints based on the FSANZ NPSC system¥
* Supplemented foods (SFs) were defined as foods containing added vitamins, minerals, amino acids, or caffeine added in amounts beyond what is
permissible for fortification/enrichment purposes according to the FDR. Food subcategories containing at least 10 SFs were analyzed. ¥ Products meeting
specific cut points (beverages: <1; all other foods except for cheese, edible oil, edible oil spreads, margarine, or butter: <4) based on the FSANZ NPSC
system are considered ‘healthy’ and would be permitted to carry a health claim in Australia/New Zealand. ǂ p < 0.05 was considered significant.
Food subcategory
SFs (n)
Non-SFs (n)
Number of foods meeting ‘healthy’
cutpoints (%)
p-valueǂ
SFs
Non-SFs
Carbonated and non-carbonated
beverages and wine coolers
15
253
8 (53)
104 (41)
0.35
Juices, nectars and fruit drink
substitutes 24 612 20 (83) 379 (62) 0.03
42
Table 8. NPSC nutrient profile scores* of functional foods¥ (FFs) and non-functional foods (non-FFs) in the Canadian marketplace in 2013
Food subcategory
FFs (n)
Non-FFs (n)
Nutrient profiling score
Mdn (Q1, Q3)ǂ
p-value
Direction of
significanceѱ
FF Non-FF
Cookies and graham wafers
22
369
11 (9, 13)
20 (15, 23)
< 0.0001
Positive
Grain-based bars (with filling or
coating)
33
73
11 (9, 12)
16 (10, 19)
0.0002
Positive
Grain-based bars (without filling or
coating)
17
83
4 (2, 9)
9 (8, 11)
0.002
Positive
Carbonated and non-carbonated
beverages and wine coolers
14
254
0 (0, 2)
1 (0, 2)
0.24
NS
RTE breakfast cereals (puffed, coated,
w/o fruit or nut, very high fibre)
19
58
10 (8, 13)
12 (3, 14)
0.28
NS
RTE breakfast cereals (fruit and nut
type, granola, biscuit type)
30
140
2 (1, 10)
1 (-1, 8)
0.09
NS
Pastas without sauce
23
416
-6 (-6, -6)
-4 (-4, -3)
< 0.0001
Positive
Plant-based beverages, milk,
buttermilk and milk-based drinks
14
233
0 (-1, 2)
-1 (-1, 0)
0.1
NS
Yogurt
74
159
0 (-2, 2)
-1 (-2, 1)
0.09
NS
Juices, nectars, and fruit drink
substitutes
14
622
0 (0, 0)
0 (-3, 1)
0.67
NS
43
* Nutrient profile scores are based on the FSANZ Nutrient Profiling Soring Criterion (NPSC). ¥ Functional foods (FFs) were defined as foods containing
added ingredients other than vitamins and minerals for the purpose of providing a health benefit. Food subcategories containing at least 10 FFs were
analyzed. ǂ Q1 and Q3 refer to 25% and 75% quartile median values. ѱ A p-value < 0.05 was considered significant. Positive significance indicates that
median scores of FFs are significantly lower (or “healthier”) than median scores of non-FFs. NS indicates no significance in nutrient profiling scores.
Products meeting specific cut points (beverages: <1; cheese, edible oil, edible oil spreads, margarine, or butter: <28; all other foods: <4) based on the
NPSC system are considered ‘healthy’ and would be permitted to carry a health claim in Australia/New Zealand.
44
Table 9. Number and proportion of FFs* and non-FFs meeting ‘healthy’ cutpoints based on the FSANZ NPSC system¥
* Functional foods (FFs) were defined as foods containing added ingredients other than vitamins and minerals for the purpose of providing a health benefit. Food
subcategories containing at least 10 FFs were analyzed. ¥ Products meeting specific cut points (beverages: <1; all other foods except for cheese, edible oil, edible
oil spreads, margarine, or butter: <4) based on the FSANZ NPSC system are considered ‘healthy’ and would be permitted to carry a health claim in
Australia/New Zealand. ǂ p < 0.05 was considered significant.
Food subcategory
FFs (n)
Non-FFs (n)
Number of foods meeting ‘healthy’
cutpoints (%)
p-valueǂ
FFs
Non-FFs
Cookies and graham wafers
22
369 0 (0) 3 (1) 0.67
Grain-based bars (with filling or coating)
33
73 0 (0) 2 (3) 0.34
Grain-based bars (without filling or coating)
17
83 8 (47) 5 (6) <.0001
Carbonated and non-carbonated beverages and wine
coolers
14
254 8 (57) 104 (41) 0.23
RTE breakfast cereals (puffed, coated, w/o fruit or nut,
very high fibre)
19
58 4 (21) 15 (26) 0.67
RTE breakfast cereals (fruit and nut type, granola, biscuit
type)
30
140 18 (60) 92 (66) 0.55
Pastas without sauce
23
416 23 (100) 413 (99) 0.68
Plant-based beverages, milk, buttermilk and milk-based
drinks
14
233 9 (64) 175 (75) 0.37
Yogurt
74
159 70 (95) 150 (94) 0.94
Juices, nectars and fruit drink substitutes
14
622 13 (93) 388 (62) 0.02
45
Table 10. Breakdown of NPSC scores¥ of functional foods (FFs)
ǂ compared to non-functional foods (non-FFs) per food subcategory
Food subcategory*
FFs
(n)
Non-FFs
(n)
Nutrient
Median points scored (Q1, Q3)
p-value
Direction of
significance
FFs
Non-FFs
Cookies and graham
wafers
22
369
Energy
5 (4, 5)
5 (5, 6)
0.003
Positive
Saturated fat
3 (3, 4)
8 (4, 10)
< .0001
Positive
Total sugars
6 (5, 7)
7 (5, 8)
0.002
Positive
Total sodium
2.5 (1, 3)
3 (2, 4)
0.27
NS
FVNL
0 (0, 0)
0 (0, 0)
< .0001
Positive
Protein
0 (0, 0)
0 (0, 0)
0.34
NS
Fibre
5 (5, 5)
3 (0, 3)
< .0001
Positive
Grain-based bars (with
filling or coating)
33
73
Energy
4 (4, 5)
5 (4, 5)
0.001
Positive
Saturated fat
3 (1, 4)
5 (1, 7)
0.003
Positive
Total sugars
7 (5, 7)
7 (6, 8)
0.003
Positive
Total sodium
2 (2, 3)
2 (1, 3)
0.98
NS
FVNL
0 (0, 0)
0 (0, 0)
0.20
NS
Protein
0 (0, 0)
0 (0, 0)
0.09
NS
Fibre
5 (5, 5)
3 (3, 5)
< .0001
Positive
46
Table 10. (continued)
Food subcategory
FFs
(n)
Non-FFs
(n)
Nutrient
Median points scored (Q1, Q3)
p-value
Direction of
difference
FFs
Non-FFs
Grain-based bars
(without filling or
coating)
17
83
Energy
4 (4, 5)
5 (4, 5)
0.008
Positive
Saturated fat
1 (1, 3)
1 (1, 3)
0.83
NS
Total sugars
4 (4, 5)
6 (5, 7)
0.001
Positive
Total sodium
3 (2, 3)
2 (2, 3)
0.02
Negative
FVNL
0 (0, 0)
0 (0, 0)
0.88
NS
Protein
3 (0, 5)
0 (0, 0)
< .0001
Positive
Fibre
5 (5, 5)
5 (4, 5)
0.003
Positive
RTE breakfast cereals
(puffed, coated, w/o
fruit or nut, very high
fibre)
19
58
Energy
4 (4, 5)
4 (4, 4)
0.02
Negative
Saturated fat
0 (0, 0)
0 (0, 0)
0.26
NS
Total sugars
6 (4, 7)
4 (2, 7)
0.39
NS
Total sodium
5 (4, 6)
5 (4, 7)
0.59
NS
FVNL
0 (0, 0)
0 (0, 0)
0.33
NS
Protein
0 (0, 0)
0 (0, 4)
0.54
NS
Fibre
5 (5, 5)
3 (3, 5)
< .0001
Positive
47
Table 10. (continued)
Food subcategory
FF
(n)
Non-FF
(n)
Nutrient
Median points scored (Q1, Q3)
p-value
Direction of
significance
FFs
Non-FFs
RTE breakfast cereals
(fruit and nut type,
granola, biscuit type)
30
140
Energy
4 (4, 5)
4 (4, 5)
0.02
Positive
Saturated fat
0 (0, 0)
0 (0, 2)
0.01
Positive
Total sugars
4.5 (3, 5)
4 (3, 5)
0.28
NS
Total sodium
2 (2, 5)
1 (0, 2)
< .0001
Negative
FVNL
0 (0, 0)
0 (0, 0)
0.78
NS
Protein
3.5 (0, 5)
5 (0, 5)
0.21
NS
Fibre
5 (5, 5)
5 (5, 5)
0.55
NS
Pastas without sauce
23
416
Energy
4 (4, 4)
4 (4, 4)
0.68
NS
Saturated fat
0 (0, 0)
0 (0, 0)
0.26
NS
Total sugars
0 (0, 0)
0 (0, 0)
0.37
NS
Total sodium
0 (0, 0)
0 (0, 0)
0.24
NS
FVNL
0 (0, 0)
0 (0, 0)
0.28
NS
Protein
5 (5, 5)
5 (5, 5)
0.06
NS
Fibre
5 (5, 5)
3 (3, 3)
< .0001
Positive
48
Table 10. (continued)
Food subcategory
FF
(n)
Non-FF
(n)
Nutrient
Median points scored (Q1, Q3)
p-value
Direction of
significance
FFs
Non-FFs
Yogurt
74
159
Energy
1 (0, 1)
1 (0, 1)
0.91
NS
Saturated fat
1 (0, 1)
0 (0, 1)
0.003
Negative
Total sugars
2 (2, 2)
2 (0, 2)
0.04
Negative
Total sodium
0 (0, 0)
0 (0, 0)
1.00
NS
FVNL
0 (0, 0)
0 (0, 0)
0.09
NS
Protein
2 (2, 3)
2 (2, 4)
0.36
NS
Fibre
0 (0, 0)
0 (0, 0)
0.04
Positive
* As large proportions of FFs contained added novel fibres, a subanalysis was conducted to examine the contribution of these added
ingredients in determining the final NPSC scores of FFs. Food subcategories containing beverages were not analyzed, as beverages are
not permitted to score fibre points according to the NPSC.
49
Table 11. Level of nutrition marketing on food labels of supplemented foods* (SFs) and non-supplemented foods (non-SFs) in
Canada in 2013
* Supplemented foods (SFs) were defined as foods containing added vitamins, minerals, amino acids, or caffeine added in amounts beyond what is
permissible for fortification/enrichment purposes according to the FDR. Food subcategories containing at least 10 SFs were analyzed. ¥ Total marketing
items include the total number of regulated claims (i.e. nutrient content claims and health claims) and Front-of-Pack systems (FOPS). ѱ Mdn represents
median values. Q1 and Q3 represent 25% and 75% quartile median values. ǂ p < 0.05 is considered significant. Positive significance denotes that SFs had
a significantly greater number of total marketing/regulated claims/FOPS than non-SFs. NS represents no significance.
Food
subcategory
SFs
Non- SFs
Total marketing
items¥
Mdn (Q1, Q3)ѱ
Significance
(p)ǂ
Regulated claims
Mdn (Q1, Q3)
Significance
(p)
FOPS
Mdn (Q1, Q3)
Significance
(p)
SFs
Non-SFs
SFs
Non-SFs
SFs
Non-SFs
Carbonated and
non-carbonated
beverages and
wine coolers
15
253
2 (1, 3)
0 (0, 2)
Positive
(.0005)
1 (1, 3)
0 (0, 1)
Positive
(.0002)
0 (0, 1)
0 (0, 0)
NS
(.094)
Juices, nectars
and fruit drink
substitutes
24
612
4 (3.5, 5)
2 (1, 3)
Positive
(<.0001)
3 (2, 4)
1 (1, 2)
Positive
(<.0001)
1 (1, 1)
0 (0, 1)
Positive
(.0015)
50
Table 12. Level of nutrition marketing on food labels of functional foods* (FFs) and non-functional foods (non-FFs) in Canada in 2013
Food subcategory*
FFs
(n)
Non-
FFs (n)
Total marketing
items¥
Mdn (Q1, Q3)
Significance
(p)ǂ
Regulated claims
Mdn (Q1, Q3)
Significance
(p)
FOPS
Mdn (Q1, Q3)
Significance
(p)
FFs
Non-FFs
FFs
Non-FFs
FFs
Non-
FFs
Cookies and graham
wafers
22
369
2.5 (2, 4)
0 (0,1)
Positive
(<.0001)
2 (1, 3)
0 (0, 1)
Positive
(<.0001)
1 (1, 1)
0 (0, 0)
Positive
(<.0001)
Grain-based bars
(with filling or
partial or full
coating)
33
73
2 (1, 2)
0 (0, 1)
Positive
(<.0001)
1 (1,2)
0 (0,1)
Positive
(<.0001)
1 (0, 1)
0 (0, 0)
Positive
(<.0001)
Grain-based bars
(without filling or
coating)
17
83
2 (2, 3)
1 (1, 2)
Positive
(.0008)
2 (1, 2)
1 (0, 2)
NS
(.06)
1 (0, 1)
0 (0, 1)
Positive
(.02)
Carbonated and non-
carbonated beverages
and wine coolers
14
254
2 (0, 3)
0 (0, 2)
Positive
(.02)
1 (0, 3)
0 (0, 1)
Positive
(.01)
0 (0, 1)
0 (0, 0)
NS
(.06)
Ready-to-eat
breakfast cereals
(puffed and coated,
without fruit or nut,
very high fibre)
19 58 6 (5, 7) 3 (1, 4)
Positive
(<.0001)
4 (3, 5)
2 (1, 3)
Positive
(.0004)
2 (1, 2) 1 (0, 1)
Positive
(.0005)
Ready-to-eat
breakfast cereals
(fruit and nut type,
granola, biscuit-type)
30
140
5 (4, 7)
4 (2, 6)
Positive
(.03)
3.5 (2, 6)
3 (1, 5.5)
NS (.11)
1 (1, 2)
1 (0, 1)
Positive
(.01)
51
Table 12. (continued)
* Functional foods (FFs) were defined as foods containing substances (other than vitamins and minerals) added for the purpose of providing a
health benefit. Food subcategories containing at least 10 FFs were analyzed. ¥ Total marketing items include the total number of regulated claims (i.e.
nutrient content claims and health claims) and Front-of-Pack systems (FOPS). Mdn represents median values. Q1 and Q3 represent 25% and 75% quartile
median values. ǂ p < 0.05 is considered significant. Positive significance denotes that FFs had a significantly greater number of total marketing/regulated
claims/FOPS than non-FFs. NS represents no significance.
Food subcategory*
FFs
(n)
Non-
FFs (n)
Total marketing
items¥
Mdn (Q1, Q3)
Significance
(p)ǂ
Regulated claims
Mdn (Q1, Q3)
Significance
(p)
FOPS
Mdn (Q1, Q3)
Significance
(p)
FFs
Non-FFs
FFs
Non-FFs
FFs
Non-
FFs
Pastas without sauce
23
416
3 (3, 4)
0 (0, 2)
Positive
(<.0001)
2 (1, 3)
0 (0, 2)
Positive
(<.0001)
2 (1, 2)
0 (0, 0)
Positive
(<.0001)
Plant-based
beverages, milk,
buttermilk, and milk-
based drinks
14
233
3 (3, 5)
2 (1, 4)
Positive
(.02)
3 (3, 5)
2 (1, 4)
NS
(.06)
0 (0, 1)
0 (0, 0)
NS
(.26)
Yogurt
74
159
2 (2, 3)
2 (1, 3)
Positive
(.005)
2 (2, 3)
2 (1, 2)
Positive
(.0003)
0 (0, 0)
0 (0, 0)
NS
(.24)
Juices, nectars, and
fruit drink substitutes
14
622
4 (3, 5)
1 (0, 2)
Positive
(<.0001)
3 (2, 3)
1 (0, 2)
Positive
(<.0001)
1 (1, 2)
0 (0, 1)
Positive
(<.0001)
52
3.5 Discussion
Part I of this study provides the first comprehensive analysis of the occurrence of supplemented
and functional foods in the Canadian market in 2013 and a summary of the types and amounts of
nutrients that are added to these foods. Both supplemented and functional foods made up a very
small proportion (less than 3%) of the total food market (n = 15,332).
However, when examined on a subcategory level, many food subcategories contained a large
proportion of functional foods, such as shakes and shake substitutes (36%), yogurts (32%), grain-
based bars (17-31%), and ready-to-eat breakfast cereals (18-25%). Supplemented foods were
much less common. Subcategories containing the greatest proportions of supplemented foods
were vegetable juice and drink (9%), carbonated and non-carbonated beverages and wine coolers
(6%), and juices, nectars, and fruit drink substitutes (4%). This analysis provides baseline data on
the occurrence of supplemented and functional foods in the Canadian market in 2013 and can be
used to track changes that occur over time, as nutritionally-enhanced foods are a fast-growing
sector of the food industry (26, 27) and as more products transition from NHPs to foods with
NFts.
Amongst supplemented foods, B vitamins were the most commonly added micronutrient. Most B
vitamins, with the exceptions of niacin/vitamin B1 and vitamin B6, do not have defined ULs, and
thus manufacturers have greater safety margins to add them to foods in large amounts. The
highest amount seen, in relation to the RDA, of any vitamin added to a supplemented food was
12 µg of vitamin B12, an amount that is 5 times the RDA for adults and nearly 7 times the RDA
for children. Amongst vitamins and minerals that have defined ULs, two foods were found to
contain levels of niacin/vitamin B1 that exceeded the UL of adults and would be nearly two
times the UL of children. The consumption of these foods may lead to negative symptoms
associated with excess intake of niacin, such as flushing, nausea, vomiting, and symptoms of
liver toxicity (78). Adverse health effects due to high intakes of vitamins and minerals are an
area of even greater concern in members of the population that have lower RDAs and ULs, such
as children under the age of 13, and if individuals are consuming more than the recommended
amount of these SFs, which is typically one to two servings per day, or those already consuming
supplements. However, in the TMAL guidance document for supplemented foods that was
53
released in February 2016, after this work was completed, iron and folic acid could no longer be
added to SFs and, using the newly developed two-path approach to setting maximum levels of
addition, added magnesium, calcium, zinc, and potassium in many of the products surveyed
would exceed Path 1 levels and thus cautionary statements would be required on such foods (20).
In addition to vitamins and minerals, many supplemented beverages contained high levels of
caffeine. Although maximum levels of caffeine addition to beverages have been set in documents
published by Health Canada (18), there is currently no safe level of caffeine consumption that
has been established for children and adolescents, and caffeinated beverages have been deemed
unsuitable for consumption in these populations (79). Children and adolescents are at higher risk
of developing caffeine toxicity, including serious side effects such as adverse cardiovascular
effects, seizures, and death (80). Although some SFs, particularly those containing high levels of
caffeine, are required to carry cautionary statements (18), such as ‘not recommended for persons
under 18 years of age’, these products are easily accessible to all members of the population, as
they are sold alongside other beverages in grocery stores, and the effectiveness of warning labels
in promoting safe consumption has not been extensively examined, although a recent study
shows that warning labels on energy drinks may lead to decreased consumption in adolescents
but not adults (81). As reports of adverse health effects associated with the consumption of
supplemented foods and beverages are increasing (82), it is an area of public health concern to
introduce methods to restrict the use of these products amongst susceptible members of the
population. In addition, it is necessary to conduct studies to track the consumption of SFs in the
Canadian population, in particular amongst children and adolescents, as there is currently no data
available on this topic. Unfortunately the CCHS 2015 will not be tracking consumption of these
products at the brand level, and given the wide range of addition between minimum and
maximum levels (e.g. niacin 5.8-39.1 mg, a 6.7 fold difference or vitamin B6 0.5-7.0 mg, a 14
fold difference) excess in some groups could be much higher than the general median in the
latest CNF 2015.
With regards to functional foods, the most commonly added substances were found to be
inulin—a novel and prebiotic fibre—and probiotic bacterial cultures. Consuming high doses of
inulin has been associated with short-term gastrointestinal side effects, such as bloating,
flatulence, and diarrhea (83), and although probiotics are generally well-tolerated amongst
54
healthy individuals, there are concerns surrounding an increased risk of sepsis if consumed by
particular high-risk populations, such as immunocompromised individuals (84). In addition,
functional foods containing high levels of protein isolates/concentrates may not be suitable for
consumption amongst certain individuals, such as those with compromised kidney function (85).
Despite these concerns, the functional foods that were surveyed in the present study generally
did not contain added substances that were associated with serious side effects. However, as the
functional food market continues to grow at an increasing rate, it is important to monitor FFs to
track the types of substances that continue to be added to foods. In addition, it would be useful to
survey the consumption patterns of functional foods amongst individuals in the Canadian
population to determine the extent to which FFs contribute to dietary fibre intakes, rather than
from traditional sources of dietary fibre such as fruits, vegetables, and whole grains
recommended by the Canadian Food Guide (66).
Part II of this study provides the first comprehensive assessment of the nutritional quality and
level and type of nutrition marketing of supplemented foods and functional foods in the
Canadian food market. Contrary to concerns raised by health professionals and others (5), we
found that SFs and FFs were either more healthy (i.e. had lower median scores) or as equally
healthy as foods without supplemented or functional ingredients when expressed at the
subcategory level. However, in 40% of the subcategories analyzed (4 out of 10 subcategories),
functional foods were rated as ‘less healthy’ foods that would not be permitted to carry health
claims under FSANZ, despite the fact that, in most cases, they were still healthier than the non-
functional foods in these subcategories. This finding suggests that many foods that are being
enhanced with functional ingredients are types of foods that generally have low nutritional value,
such as cookies and graham wafers, grain-based bars, and some ready-to-eat breakfast cereals.
This may be worrisome if consumers increase their consumption of certain types of foods that
have an overall poorer nutritional value, such as cookies and high-sugar cereals, if they contain
functional ingredients. A Canada-wide survey revealed that the majority of teens and adults
would be more likely to consume foods with low nutritional value, such as soft drinks and salty
snacks, if they were fortified with nutrients (71). A study conducted in 2004 found that Canadian
parents viewed the addition of vitamins and minerals to foods of poor nutritional quality as an
55
added bonus (72). Additionally, a conjoint study investigating Danish, Finnish, and American
consumer perceptions of functional foods found that the addition of substances such as
bioactives to foods was perceived as providing a greater health benefit when they were added to
conventionally ‘unhealthy’ foods, such as spreads, compared to ‘healthy’ foods, such as yogurt
(73).
Supplemented foods, on the other hand, seem to be an area of less concern, as they were deemed
sufficiently healthy (i.e. had NPSC scores within category-specific thresholds) to carry health
claims under FSANZ in both subcategories analyzed. This finding may be due to the fact that
there are fewer supplemented foods being sold in Canadian grocery stores (n = 52) than there are
functional foods (n = 326), and fewer types of foods are currently permitted to be supplemented,
namely beverages. It is still important to track the nutritional quality of supplemented foods in
the Canadian food supply over time as they gain popularity and become more widespread
amongst food categories, particularly as more natural health products in food format transition to
foods under the Health Canada regulatory framework (16).
It is important to note that both supplemented foods and functional foods in all subcategories
analyzed were more heavily marketed overall than comparable foods without supplemental or
functional ingredients, regardless of the nutrient profile scores of these foods. This finding
suggests that the level of marketing on foods with added ingredients is high and not indicative of
the overall nutritional quality of the food. This excessive marketing is an area of concern, since
Health Canada currently does not use a nutrient profiling system requiring foods that carry
nutrient content and health claims to meet minimum nutritional quality criteria, and there are no
specific regulations to govern the use of FOPS on food packaging. As a result, many foods of
poor nutritional quality, such as foods high in sugar or sodium, may carry a large array of
nutrition-related claims on their packaging. Combined with the result that nutrients are often
added to foods occurring in ‘less healthy’ food subcategories, this heavy marketing on products
with added nutrients may lead consumers to inadvertently make less healthy dietary choices, as
multiple studies have shown that consumers form more positive attitudes towards a product if it
carries health claims (41-44), especially if these claims appear on products that are commonly
perceived as ‘less healthy’ (47). Additionally, a study specifically examining the effect of health
claims appearing on functional food labels on consumer perceptions found that health claims had
56
a positive effect on consumers’ perceived healthiness of these products (73). To prevent the
misleading of consumers and potential negative effects on dietary patterns, Health Canada
should tighten the regulations governing nutritionally-enhanced foods, particularly those
surrounding functional foods, requiring foods to have overall ‘healthy’ nutrient profiles in order
to be permitted to contain added vitamins, minerals, bioactives, novel fibres, and other nutrients.
In addition, the use of nutrient content and health claims on food labels should be more strictly
regulated, and FOP systems and symbols should be included in the FDR, requiring that minimum
nutritional quality standards be met, in order to carry such claims, as is done in Australia, New
Zealand, Ireland, Norway, and other countries (1).
There are certain limitations to this study. First, the classification of foods as either supplemented
foods or functional foods were based on inclusion and exclusion criteria specific to this study,
since Health Canada had not yet provided finalized definitions or classification criteria for either
of these types of foods at the time the analyses were completed. In addition, a number of foods
that would be considered as SFs may not have been captured in this study because at the time of
collection of the FLIP 2013, many SFs had not made the full transition to the food regulatory
framework and did not yet carry a standardized NFt on their labels. Only SFs carrying a
standardized NFt were included in this study. As a result, the occurrence of SFs in the Canadian
food market is likely underestimated in this study.
In addition, it was assumed that the nutrient content information in the NFt used to calculate
FSANZ nutrient profiling scores was accurate. The accuracy of the NFt in reflecting the true
nutritional composition of foods is assessed by the Canadian Food Inspection Agency (CFIA)
and was found to be satisfactory for the majority of foods (86). However, the possibility remains
of unsatisfactory reporting of nutrient content values in the NFt of some products. Also, the
nutrient profiling model used to calculate the nutritional value of a food was originally created
for use in Australia and New Zealand, not Canada. However, as there is currently no validated
Canadian system that has been intended for use as a nutrient profiling model, the FSANZ model
was chosen as an appropriate substitute. Additionally, quantitative declaration of ingredients,
such as fruits, vegetables, nuts, and legumes, is not required to be provided by manufacturers on
food labels in Canada. Therefore, the fruit/vegetable/nut/legume (FVNL) content of a food could
not be directly determined to calculate the NPSC score. However, the rank of FVNL ingredients
57
in the Ingredients List was used to approximate the percentage of FVNL in a product, since
ingredients are listed by weight in descending order in the Ingredients list. Although this method
was standardized and the cutpoints are quite high, the FVNL content scores were still only
estimates and may lack complete accuracy. A final limitation to consider is that the NPSC
system considers saturated fat a ‘negative’ nutrient. However, the association between saturated
fat and the risk of chronic diseases, such as cardiovascular disease, is a controversial topic and
remains unclear (68).
Through the introduction of supplemented and functional foods, the food industry today has
greater freedom to add a variety of nutrients to foods, and consumers, in turn, have a wider range
of products to choose from to fulfill their dietary needs. However, the present study supports
concerns that: i) consumers may inadvertently consume nutritionally-enhanced products,
particularly SFs, in ways that may lead to adverse health effects, such as high intakes of
particular nutrients that are not appropriate for certain age groups (5); and ii) that the increasing
popularity of nutritionally-enhanced foods may lead consumers to overlook the overall
nutritional content of the foods they are purchasing, such as high levels of sugar and sodium, and
result in negative repercussions on population health.
The findings of this study can provide valuable information to researchers and the government to
aid in the creation of appropriate regulatory policies regarding nutritionally-enhanced products,
such as: the use of a validated nutrient profiling system to regulate the use of nutrition-related
marketing on food packages, as several other countries, such as the United Kingdom, Australia,
and New Zealand, have done; and governing the types of foods that may be permitted to contain
added nutrients. Additionally, new approaches should be made to guide consumers in the
appropriate use of nutritionally-enhanced foods and allow for their safe consumption. For
example, product specific labeling or logos can be used to help consumers distinguish products
with added nutrients from other foods. Further studies examining the consumption of brand
specific supplemented and functional foods in the Canadian population are required to further
analyze the extent to which these types of foods are contributing to nutrient intakes and affecting
the dietary patterns of Canadians.
58
Chapter 4
4 – Study 2: The nature and prevalence of voluntarily fortified
foods with high levels of added vitamins and minerals in the
Canadian marketplace
4.1 Abstract
Although the majority of Canadians have adequate intakes of most micronutrients (87), a variety
of foods in Canada are being voluntarily fortified with high levels of vitamins and minerals.
Researchers have raised concerns that the consumption of such foods may cause excessive
micronutrient intakes in certain population subgroups, such as children and adolescents; and that
food manufacturers are adding vitamins and minerals to foods that are otherwise unhealthy. The
objective of this study was to determine and measure the prevalence of voluntarily fortified foods
with high levels of vitamins and minerals (VHVMs) in the Canadian market (n = 15 332), their
nutritional quality, and their levels of nutrition-related marketing. A total of 923 foods were
classified as VHVMs. A wide range of food types, including ready-to-eat breakfast cereals, fruit
juices, nectars and fruit drinks, and plant-based beverages, contained high proportions of
VHVMs. Using the validated nutrient profiling model created by FSANZ, in 50% of the food
categories analyzed, VHVMs were less healthy than comparable foods without these
vitamin/mineral additions and in 25% of food categories, VHVMs were considered unhealthy
foods. Additionally, VHVMs carried more nutrition-related marketing claims than non-VHVMs
in all food categories. These findings provide baseline information on the prevalence and
attributes of VHVMs in Canada and support concerns surrounding the potential for fortified
foods to contribute to excess intakes of certain vitamins and minerals, such as folic acid and iron,
and the displacement of healthy foods. Further studies should be conducted to measure the
consumption of these foods in the Canadian population and evaluate the impact of VHVMs on
population health.
59
4.2 Introduction
In Canada, the fortification of foods with nutrients, such as vitamins and minerals, has
historically been used as a method to prevent and correct nutrient deficiencies in the population
and address the illnesses associated with them (7). When fortification was first introduced in the
1940s, it was hugely successful in eliminating nutrient-deficiency related illnesses, such as goitre
and rickets, in the population. Presently, however, vitamin and mineral deficiency is no longer
viewed as a pressing health issue, as the majority of Canadians are consuming most
micronutrients in adequate, and sometimes even excessive, amounts (87). Yet, the fortified food
market continues to grow and high levels of vitamins and minerals continue to be added to a
wide range of foods (25).
There are two forms of fortification defined in the Food and Drug Regulations (FDR):
mandatory fortification—which requires that certain micronutrients must be added to specific
foods, such as the addition of vitamin D to milk—and voluntary fortification—which allows for
a range of micronutrients to be voluntarily added to certain foods, such as the addition of B
vitamins to breakfast cereals (88). For both mandatory and voluntary fortification, vitamins and
minerals may be added to foods only in prescribed amounts laid out in the FDR (10). The
maximum levels of vitamin and mineral addition to foods are based on the highest
Recommended Daily Allowances (RDAs)/Adequate Intakes (AIs) and Tolerable Upper Levels
(ULs) within the population, typically values indicated for males 19 years of age and older (64,
77). However, voluntarily fortified foods, such as breakfast cereals and fruit juices, tend to be
marketed to all members of the population, including children (23). There is concern that this
method of setting maximum levels may potentially lead to excessive micronutrient intakes in
certain segments of the population, such as children (23, 25, 89).
Researchers and health professionals are also wary that manufacturers may use voluntary
fortification as a marketing strategy and add vitamins and minerals to foods that are less healthy
to increase sales (5, 89). Increased prevalence of voluntarily fortified foods of poor nutritional
value, particularly if combined with heavy marketing on the labels of such foods, may lead to the
displacement of ‘healthy’ foods and have significant negative impacts on the dietary patterns of
Canadians. Canadian studies have shown that adults and teens are more likely to increase their
60
consumption of less healthy foods, such as soft drinks and salty snacks, if they are fortified (71),
and that Canadian parents view the addition of vitamins and minerals to foods of low nutritional
quality as an added bonus (72). In addition, it has been shown that health claims on food labels
positively affect consumer attitudes towards a food (41-44), even if those foods have a ‘less
healthy’ image, such as candies and spreads (47). Although the FDR enforces specific
regulations surrounding the use of certain claims, such as nutrient content and health claims,
Canada currently does not use a nutrient profiling system requiring foods to have an overall
healthy profile to carry a claim. Additionally, there are no specific regulations governing the use
of FOP systems (FOPS) on food labels.
Although some studies have been conducted on the health outcomes of voluntary fortification in
other countries (24, 25), there is currently a lack of data on the occurrence and nature of
voluntarily fortified foods to test these hypotheses in Canada. The objectives of this study were
to assess the frequency and nutritional quality of voluntarily fortified foods with high levels of
added vitamins and minerals (VHVM) in the Canadian marketplace, as well as to determine if
such foods are more heavily marketed than other comparable foods without such additions.
4.3 Methodology
4.3.1 Data collection
Food Label Information Program 2013 (FLIP 2013)
Data was acquired using the University of Toronto Food Label Information Program 2013 (FLIP
2013), an online database containing 15,401 prepackaged foods and beverages from the top four
supermarket chains of Canada—Loblaws, Sobeys, Metro, and Safeway—and representing 75.4%
of the grocery retail marketshare (74). FLIP 2013 provides a cross-sectional nutritional overview
of prepackaged products in the Canadian marketplace in 2013. Complete details of the FLIP
2013 methodology can be found in Bernstein et al. (2016)(75).
10 products carried manufacturer labelling errors and were removed from the initial product
collection. Furthermore, meal replacements, foods intended for children under the age of 4, and
products lacking a standard Canadian NFt (e.g. Natural Health Products) were excluded from
this analysis, leaving a final sample of 15,332 products. The Nutrition Facts Table (NFt) and
61
Ingredients List of all remaining foods and beverages were examined to obtain information on
the type and amount of added ingredient in each product.
4.3.2 Data analysis
Classifying foods and beverages with high levels of voluntary fortification
In this study, a food or beverage was classified as having high levels of voluntary fortification
(VHVM) if it complied with the regulations pertaining to voluntary fortification in the FDR (10)
and it contained a vitamin or mineral in an amount that is greater than 25% of the Daily Value
(DV). Foods and beverages that did not contain added nutrients, contained added nutrients in
lower amounts (≤25% of the DV), or contained added nutrients for purposes other than voluntary
fortification (e.g. mandatory fortification or enrichment, or food additive purposes) were
excluded from this group and classified as non-VHVMs. All foods were categorized based on
food subcategories in Schedule M of the FDR (76).
Nutrient profiling
The validated Nutrient Profiling Scoring Criterion (NPSC) system, created by Food Standards
Australia New Zealand (FSANZ) (54), was used to create a nutrient profile score for each
product (Appendix 4). The FSANZ model separates foods into three categories: beverages
(Category 1); cheese, edible oil, edible oil spreads, butter and margarine (Category 3); and any
food other than those included in categories 1 and 3 (Category 2). A score is then created for
each food or beverage according to a points-based system relying on category-specific nutrient
content thresholds. Points are added for ‘negative’ nutrients, such as energy content, saturated
fat, total sugars, and sodium, and points are deducted for ‘positive’ nutrients, such as
fruit/vegetable/nut/legume, protein, and fibre content. Scores fall on a range of -18 to 81, with
lower scores indicating ‘healthy’ foods and higher scores indicating ‘less healthy’ foods. Foods
in categories 1, 2, and 3 are eligible to carry health claims under FSANZ only if their final scores
are less than 1, 4, or 28, respectively.
Marketing
All nutrition-related marketing on prepackaged products in FLIP 2013 were recorded and
classified into several categories, including regulated claims (i.e. nutrient content claims, disease
62
risk reduction claims, and function claims) and Front-of-Pack nutrition rating systems (FOPS).
Each regulated claim or FOPS was counted individually as one marketing item. If a product
repeated the same claim or FOPS multiple times on different panels, the claim or FOPS was
counted only once. The number of regulated claims, FOPS, and total marketing items occurring
on VHVMs were compared to non-VHVMs.
Statistical analyses
All statistical analyses were performed using SAS version 9.3 (Statistical Analysis Software Co,
Cary NC). Categorical variables are given as percentages and frequencies and continuous
variables are quantified as medians, Q1s, and Q3s. For food subcategories containing at least
10% of foods with high levels of voluntary fortification, the Wilcoxon signed rank test was used
to determine if there were any statistical differences in median NPSC scores compared to non-
VHVMs. Chi squared tests were used to compare the proportions of VHVMs and non-VHVMs
meeting ‘healthy’ cutpoints based on the FSANZ NPSC system to be eligible to carry health
claims. Additionally, the number of total marketing items, regulated claims, and FOPS between
VHVMs and non-VHVMs were compared within each food subcategory. A P value of <0.05
was considered significant.
4.4 Results
Frequency and proportion of VHVMs and most commonly added vitamins and
minerals
A total of 923 foods and beverages (6% of total database foods) were classified as VHVMs.
Major food categories containing the greatest number of VHVMs were cereals and other grain
products, and fruit juices (Table 13). Food subcategories containing the greatest proportions of
VHVMs were ready-to-eat breakfast cereals (puffed and coated, without fruit and nut) (77%),
fruit juices, nectars, and fruit juice substitutes (54%), vegetable juice and drink (47%), fruit
(fresh, canned, or frozen) (43%), plant-based beverages, milk, buttermilk, and milk-based
beverages (39%), hot breakfast cereals (37%), pastas without sauce (35%), and ready-to-eat
breakfast cereals (fruit and nut type, granola, biscuit type) (33%). The top five most commonly
added vitamins and minerals include vitamin C (n = 462), thiamine (n = 275), folic acid (n =
154), and iron (n = 156) (Table 14).
63
FSANZ nutrient profile scores of VHVMs in comparison to other foods
In four out of eight subcategories—hot breakfast cereals, ready-to-eat breakfast cereals (puffed
and coated, without fruit and nut, very high fibre), juices, nectars, and fruit-juice substitutes, and
fruits (fresh, canned, or frozen)—VHVMs had significantly higher (p<0.0001) NPSC scores (i.e.
were ‘less healthy’) than non-VHVMs within the same subcategories (Table 15). In two of these
subcategories—hot breakfast cereals and ready-to-eat breakfast cereals (puffed and coated,
without fruit or nut)—significantly greater proportions of VHVMs did not meet ‘healthy’
cutpoints compared to non-VHVMs (Table 16). Additionally, the median NPSC scores of
VHVMs in these subcategories deemed them ineligible to carry health claims, whereas the
median NPSC scores of non-VHVMs in the same subcategories were sufficient to allow these
foods to carry health claims.
In two out of eight subcategories—plant-based beverages, milk, buttermilk, and milk-based
drinks, and pastas without sauce—VHVMs had significantly lower (p<0.05) FSANZ NPSC
scores (i.e. were ‘more healthy’) than comparable non-VHVMs. Additionally, a significantly
greater proportion of VHVMs in the plant-based beverages, milk, buttermilk, and milk-based
drinks subcategory met cutpoints to be rated as ‘healthy’, in comparison to non-VHVMs in this
subcategory.
In the remaining two categories—ready-to-eat breakfast cereals (fruit and nut type, granola,
biscuit type) and vegetable juice and drink—there were no statistical differences in median
NPSC scores between VHVMs and non-VHVMs. There were also no statistical differences in
the proportions of VHVMs and non-VHVMs meeting ‘healthy’ cutpoints, with the majority of
both types of foods considered healthy in these subcategories. However, in the ready-to-eat
breakfast cereals (fruit and nut, granola, biscuit type) subcategory, there were still large
proportions of both VHVMs (37%) and non-VHVMs (34%) that did not meet the cutpoints to be
rated as ‘healthy’.
Marketing of VHVMs in comparison to other foods
In all eight subcategories, VHVMs had significantly greater (p<0.05) numbers of total marketing
items on product labels in comparison to non-VHVMs (Table 17). In all but two subcategories,
VHVMs carried a significantly greater number of regulated claims (i.e. nutrient content,
64
function, and disease risk reduction claims) than non-VHVMs, and in six out of eight
subcategories, a significantly greater number of FOPS occurred on the labels of VHVMs
compared to non-VHVMs.
65
Table 13. The prevalence of voluntarily fortified foods with high levels of added vitamins and
minerals (VHVMs) in the Canadian market in 2013
Food category
Total foods
N
Number of
VHVMs
n (% of total N)
Bakery products
Pies, tarts, cobblers, turnovers and other
pastries
101
3 (3)
Beverages
Carbonated and non-carbonated beverages and
wine coolers
268
8 (3)
Cereals and other grain products
Pastas without sauce
439
154 (35)
Ready-to-eat breakfast Cereals (puffed and
coated, without fruit or nuts, very high fibre)
77
59 (77)
Ready-to-eat breakfast cereals, (fruit and nut
type, granola, biscuit type)
170
56 (33)
Hot breakfast cereals
107
40 (37)
Dairy products and substitutes
Plant-based beverages, milk, buttermilk and
milk-based drinks, such as chocolate milk
247
97 (39)
Fruit and fruit juices
Juices, nectars and fruit drink substitutes
636
342 (54)
Fruit, fresh, canned, or frozen
278
120 (43)
Vegetables
Vegetable juice and vegetable drink
43
20 (47)
Combination Dishes
Not measurable with a cup
521
2 (<1)
66
Table 13. (Continued)
Food Category Total foods
N
Number of
VHVMs
n (% of total N)
Salads
Salads, such as egg, fish, shellfish, bean, fruit,
vegetable, meat, ham or poultry salad
47
1 (2)
Snacks
Chips, pretzels, popcorn, extruded snacks,
grain-based snack mixes, fruit-based snacks
562
13 (2)
Desserts
Custard, gelatin and pudding
395
7 (2)
67
Table 14. Vitamins and minerals present in VHVMs* in the Canadian market in 2013
*VHVMs were defined as foods containing greater than 25% of the Daily Value (DV) of an added
vitamin or mineral in accordance with voluntary fortification policies stated in the Canadian Food and
Drug Regulations (FDR).
¥ Major food categories containing at least 15 VHVMs were analyzed.
Food category¥
Vitamin/mineral
Number of VHVMs containing
nutrient (% of total VHVMs)
Cereals and other grain
products
Folic acid/folate
154 (50)
Thiamine
275 (89)
Iron
156 (51)
Magnesium
3 (<1)
Niacin/niacinamide
2 (<1)
Dairy products and
substitutes
Fruit and fruit juices
Vegetables
Vitamin B12
90 (92)
Calcium
84 (86)
Vitamin D
98 (100)
Riboflavin
2 (2)
Vitamin C
462 (100)
Vitamin C
20 (100)
68
Table 15. Comparison of FSANZ nutrient profiling scores* of VHVMs¥ and non-VHVMs in Canada in 2013.
Food subcategory
VHVMs (n)
Non-VHVMs (n)
Median nutrient profiling
score (Q1, Q3)ǂ
p-value
Direction of
significanceѱ
VHVMs
Non-VHVMs
Hot breakfast cereals
40
67
9 (5, 11)
-5 (-6, -3)
<.0001
Negative
RTE cereals (puffed and
coated, without fruit or
nuts, very high fibre)
59
18
13 (10, 15)
0.5 (0, 5)
<.0001
Negative
RTE cereals (fruit and
nut type, granola, biscuit
type)
56
114
2 (0, 8)
1 (-1, 8)
0.27
NS
Pastas without sauce
154
285
-4 (-6, -4)
-4 (-4, -3)
<.0001
Positive
Plant-based beverages,
milk, buttermilk, and
milk-based drinks
97
150
-1 (-2, 0)
0 (-1, 1)
<.0001
Positive
Juices, nectars, and fruit-
juice substitutes
342
294
0 (-1, 1)
0 (-6, 1)
<.0001
Negative
Fruits (fresh, canned, or
frozen)
120
158
-1.5 (-4, 0)
-2 (-8, 0)
0.002
Negative
Vegetable juice and drink
20
23
0 (-1, 0.5)
0 (-3, 1)
0.64
NS
69
* Nutrient profiling scores were based on the FSANZ NPSC system. ¥ VHVMs were defined as foods containing greater than 25% of the Daily Value (DV) of an
added vitamin or mineral in accordance with voluntary fortification policies stated in the Canadian Food and Drug Regulations. Food subcategories containing at
least a 5% proportion and a minimum of 10 VHVMs were analyzed. ǂ Q1 and Q3 represent 25% and 75% quartile median values. ѱ p < 0.05 was considered
significant. Positive significance signifies that median scores VHVMs are significantly lower (or “healthier”) than median score values of non-VHVMs. Negative
significance indicates that median scores of VHVMs are significantly higher (or “less healthy”) than non-VHVMs. NS denotes no significance in median score
values.ⱷ Products meeting specific cut points (beverages: <1; all other foods except for cheese, edible oil, edible oil spreads, margarine, or butter: <4) based on
the NPSC system are considered ‘healthy’ and would be permitted to carry a health claim in Australia/New Zealand
70
Table 16. Number and proportion of VHVMs* and non-VHVMs meeting ‘healthy’ cutpoints based on the FSANZ NPSC system¥.
Food subcategory
VHVMs (n)
Non-VHVMs (n)
Number of foods meeting ‘healthy’ cutpoints
(%)
p-valueǂ
VHVMs
Non-VHVMs
Hot breakfast cereals
40
67
10 (25)
61 (91)
<.0001
RTE cereals (puffed and coated,
without fruit or nuts, very high fibre)
59
18
6 (10)
13 (72)
<.0001
RTE cereals (fruit and nut type,
granola, biscuit type)
56
114
35 (63)
75 (66)
0.67
Pastas without sauce
154
285
154 (100)
281 (99)
0.14
Plant-based beverages, milk,
buttermilk, and milk-based drinks
97
150
92 (95)
91 (61)
<.0001
Juices, nectars, and fruit-juice
substitutes
342
294
210 (61)
189 (64)
0.45
Fruits (fresh, canned, or frozen)
120
158
120 (100)
156 (99)
0.22
Vegetable juice and drink
20
23
15 (75)
16 (70)
0.69
* VHVMs were defined as foods containing greater than 25% of the Daily Value (DV) of an added vitamin or mineral in accordance with voluntary fortification
policies stated in the Canadian Food and Drug Regulations. Food subcategories containing at least a 5% proportion and a minimum of 10 VHVMs were
analyzed. ¥ Products meeting specific cut points (beverages: <1; all other foods except for cheese, edible oil, edible oil spreads, margarine, or butter: <4) based
on the FSANZ NPSC system are considered ‘healthy’ and would be permitted to carry a health claim in Australia/New Zealand. ǂ p < 0.05 was considered
significant.
71
Table 17. Levels of nutrition marketing on VHVMs* compared to non-VHVMs in Canada in 2013.
Food subcategory
VHVMs
(n)
Non-
VHVMs
(n)
Total marketing items
Mdn (Q1, Q3)¥
Significance
(p)ǂ
Regulated claims
Mdn (Q1, Q3) ¥
Significance
(p)ǂ
FOPS
Mdn (Q1, Q3) ¥
Significance
(p)ǂ
VHVMs
Non-
VHVMs
VHVMs
Non-
VHVMs
VHVMs
Non-
VHVMs
Hot breakfast cereals
40
67
5 (3, 5)
1 (0, 3)
Positive
(<.0001)
3 (2, 4)
1 (0, 3)
Positive
(<.0002)
1 (1, 2)
0 (0, 1)
Positive
(<.0001)
Ready-to-eat
breakfast cereals
(puffed and coated,
without fruit or nuts,
very high fibre)
59
18
4 (2, 6)
2 (1, 4)
Positive
(.02)
3 (2, 4)
2 (1, 3)
Positive
(.007)
1 (0, 2)
1 (0, 1)
NS
(.30)
Ready-to-eat
breakfast cereals
(fruit and nut type,
granola, biscuit type
cereals)
56
114
4 (2, 6)
3 (2, 4)
Positive
(.04)
3 (1.5, 4)
2 (1, 4)
NS
(.20)
1 (0, 2)
0.5 (0, 1)
Positive
(.002)
Pastas without sauce
154
285
1 (0, 3)
0 (0, 1)
Positive
(<.0001)
1 (0, 2)
0 (0, 1)
Positive
(<.0001)
0 (0, 1)
0 (0, 0)
Positive
(<.0001)
Plant-based
beverages, milk,
buttermilk, and milk-
based drinks
97
150
4 (3, 5)
2 (1, 3)
Positive
(<.0001)
4 (3, 5)
2 (1, 3)
Positive
(<.0001)
0 (0, 1)
0 (0, 0)
Positive
(.0009)
Juices, nectars, and
fruit-juice substitutes
342
294
2 (1, 3)
1 (0, 2)
Positive
(<.0001)
2 (1, 2)
1 (0, 2)
Positive
(<.0001)
1 (0, 1)
0 (0, 1)
Positive
(.0006)
Fruit (fresh, canned,
or frozen)
120
158
2 (0, 3)
1 (0, 2)
Positive
(.03)
0 (0, 1)
0 (0, 2)
NS
1 (0, 1)
0 (0, 1)
Positive
(.0003)
72
* VHVMs were defined as foods containing greater than 25% of the Daily Value (DV) of an added vitamin or mineral in accordance with voluntary fortification
policies stated in the Canadian Food and Drug Regulations. Food subcategories containing at least a 5% proportion and a minimum of 10 VHVMs were analyzed.
¥ Mdn represents median values; Q1 and Q3 represent 25% and 75% quartile median values. ǂ p < 0.05 was considered significant. Positive significance indicates
that VHVMs have a significantly higher median number of total marketing items/regulated claims/FOP than non-VHVMs. NS denotes no significant differences.
Vegetable juice and
vegetable drink
20
23
4.5
(2.5, 6.5)
1 (0, 4)
Positive
(.0005)
4 (2.5, 4)
1 (0, 3)
Positive
(.0005)
1 (1, 2)
1 (0, 1)
NS
(.08)
73
4.3 Discussion
This study provides the first comprehensive analysis of the frequency, nutritional quality, and
marketing characteristics of voluntarily fortified foods with high levels of added vitamins and
minerals (VHVMs) in the Canadian food market. Overall, over 900 foods and beverages
(approximately 6% of the food supply) contained voluntarily added vitamins and minerals in
high amounts (i.e. greater than 25% of the Daily Value). However, a number of food categories,
such as ready-to-eat breakfast cereals, plant-based beverages and milk-based drinks, and fruit
juices, nectars, and fruit juice substitutes, contained large proportions of VHVMs. These findings
confirm that many voluntarily fortified foods occur in food categories, such as breakfast cereals
and fruit juices, that are marketed towards all members of the population, including children
(23). Additionally, it should be noted that all of the food categories that contained high
proportions of VHVMs are among the top food choices of Canadian children and adolescents
(90, 91). The most commonly added vitamins and/or minerals in VHVMs were vitamin C,
thiamine, folic acid/folate, iron, and vitamin D, while vitamins and minerals that were added less
commonly (less than 10% of VHVMs) include vitamin B12, calcium, magnesium, niacin, and
riboflavin. Based on data from the Canadian Community Healthy Survey (CCHS) 2.2, the
prevalence of inadequacy for vitamin C, thiamine, folic acid, and iron was very low in Canadian
children and adolescents 13 years of age and under in 2004 (87). In individuals over the age of
14, the prevalence of inadequate vitamin/mineral intakes were uniformly high only for vitamin
A, vitamin D, calcium, and magnesium (87). Therefore, with the exception of vitamin D, most of
the vitamins and minerals that were most commonly added to VHVMs do not have evidence of
inadequacy in the Canadian population.
Researchers and health professionals are concerned that increased consumption of voluntarily
fortified foods may result in excessive nutrient intakes, especially in combination with
supplement use, in certain age/gender groups such as children (5, 89). In Canada, the use of
supplements is associated with an increased risk of vitamin/mineral intakes above the UL in both
children and adults (87), particularly in the cases of folic acid (92), zinc, and iron (87). Since
40% of Canadians take some form of vitamin/mineral supplement (87), the combined intake of
vitamins/minerals from both voluntarily fortified foods and supplements presents a real concern.
A recent study in the United States (25) found that higher exposure to voluntarily fortified foods
74
was associated with an increased risk of excessive nutrient intakes in children. It would be useful
to carry out a parallel study (25) in Canada, to analyze the extent to which voluntarily fortified
foods have the potential to lead to excessive nutrient intakes in the Canadian population,
particularly in children and adolescents.
In terms of comparing the nutritional quality of foods with high levels of voluntary fortification
to that of foods without such vitamin/mineral additions, this study found when median NPSC
scores were compared, 50% of food subcategories contained VHVMs that were significantly less
healthy than non-VHVMs. Additionally, in 25% of food subcategories, most VHVMs were not
rated as healthy foods and would not be permitted to carry health claims under FSANZ, whereas
most non-VHVMs in these categories were rated as healthy and would be able to carry health
claims. We also found that in an equal proportion (50%) of food subcategories, VHVMs were
either significantly healthier than or as equally healthy as comparable foods without high levels
of voluntary fortification. However, large proportions of VHVMs in some of these subcategories,
such as certain ready-to-eat breakfast cereals, still would not meet cutoffs to carry health claims,
despite the fact that they were not overall less healthy than comparable non-VHVMs.
Taken together, these findings suggest that: the voluntary addition of vitamins and minerals to
foods does not seem to have any strict correlation with the overall healthiness of a food; that a
large proportion of foods with high levels of voluntary fortification are less healthy than non-
voluntarily fortified foods; and that many foods with high levels of voluntary fortification would
not be considered healthy enough to carry health claims in countries that use nutrient profiling
models to regulate the use of health claims on food labels, such as Australia and New Zealand
(54). These results support the concern that consumers may inadvertently be choosing foods that
are less healthy under the false assumption that fortified foods are healthier than regular foods
because of their added vitamins and minerals (5). These concerns carry even more weight when
the high amount of marketing on voluntarily fortified foods is considered. In all food
subcategories analyzed, VHVMs, regardless of overall nutritional quality, were significantly
more heavily marketed—most carrying both a greater number of regulated claims and FOPS—
than foods without these nutrient additions. As previously mentioned, studies have shown that
Canadian consumers are more likely to include foods of low nutritional value in their diets if
they are fortified (71), and that they are more likely to form positive attitudes towards a food—
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including attitudes regarding the healthiness of a food—if the food label carries nutrition or
health-related claims (41, 42). Collectively, the findings from this analysis and other studies
support taking a cautious attitude towards the widespread addition of high levels of vitamins and
minerals to foods.
To prevent the shifting of dietary patterns and the displacement of healthy foods, the overall
nutritional quality of a food should be taken into consideration in setting regulations for the
marketing of voluntarily fortified foods. In the United Kingdom, Australia, and New Zealand,
nutrient profiling models that take into account various nutritional aspects of a food—such as
energy, saturated fat, sugar, and sodium content—are used to determine the eligibility of
products to carry nutrition-related and health claims. Currently, Health Canada does not use a
nutrient profiling system to regulate the use of nutrient content and health claims. In addition,
there are no specific regulations in Canada overseeing the use of FOP marketing on foods.
There are certain limitations to this study. First, the food database used in this analysis, FLIP
2013, represents approximately 75% of the market share in Canada (cite study 1). Therefore,
there is a certain percentage of foods in the food supply that have not been accounted for in this
analysis. Second, the nutrient content values used to calculate FSANZ nutrient profiling scores
were based on values found in the NFt on product labels, and it was assumed that this data were
accurate. The Canadian Food Inspection Agency (CFIA) uses a compliance test to assess the
accuracy of nutrient levels provided in the NFt by food manufacturers. An analysis of over 1000
foods sampled by the CFIA between 2006 and 2010 found that 16.7% of products were
unsatisfactory with regards to the accuracy with which certain nutrients, such as sodium, sugar,
and saturated fat, were reported in the NFt (86). Although the present study analyzed products
found in the market in 2013, the possibility remains that the NFt on some products may have
provided inaccurate values. In addition, the points scored for the fruit/vegetable/nut/legume
content of a product were based on the rank of ingredients in the Ingredients List, since
manufacturers are not required to provide this information in the NFt in Canada (Appendix 1).
Although the procedure was standardized (Appendix 1) and the cutpoints used were high, the
fruit/vegetable/nut/legume content of a product could only be estimated and these estimations
may lack complete accuracy. Finally, although the FSANZ nutrient profiling model has been
validated in Australia and New Zealand (1, 57), the model has not yet been validated for use in
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the Canadian market. However, as Health Canada has yet to release a validated classification
system intended for use as a nutrient profiling model, the FSANZ model was determined to be
the most appropriate model available to use in this analysis. Also, a final limitation to consider is
that the NPSC system considers saturated fat a ‘negative’ nutrient. However, the association
between saturated fat and the risk of chronic diseases, such as cardiovascular disease, is a
controversial topic and remains unclear (68).
The introduction of vitamin and mineral food fortification in Canada was one of the most
successful public health campaigns in the country and eradicated a wide array of diseases
associated with nutrient deficiencies, such as rickets and goitre (7, 8). However, the dietary and
health issues that most Canadians face today are no longer the result of a low intake of nutrients,
but rather an excessive intake of nutrients, along with rising rates of overweight and obesity in
both adults and children (2, 93). The voluntary fortification of a wide range of foods, many of
which have high levels of sugar, fat, and/or sodium, may be putting Canadians at risk of excess
nutrient intakes, such as folic acid and iron. Results from this study support the concern that
foods with added vitamins and minerals may inadvertently cause consumers to overlook the
levels of other nutrients in a food, such as sugar, fat, and sodium, and make unhealthy dietary
choices. To prevent the shifting of dietary patterns that may contribute to negative health effects,
such as obesity, Canada should follow the lead of other countries and enforce a nutrient profile-
based policy to restrict the range of foods that may contain added nutrients and govern the use of
nutrition-related marketing on the labels of voluntarily fortified foods.
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Chapter 5
5 - General Discussion
This is the first known set of studies investigating the prevalence and nature of nutritionally-
enhanced foods in Canada. This thesis aimed to conduct a comprehensive analysis on
supplemented foods, functional foods, and voluntarily fortified foods using the FLIP 2013, a
food database containing information on over 15,000 foods in the Canadian marketplace in 2013.
5.1 Overview of findings
Study 1
The overall frequency of SFs and FFs in the FLIP 2013 was relatively low (less than 3% of total
foods), with SFs (n = 52) being even less common than FFs (n = 326). However, the distribution
of SFs and FFs was not uniform amongst food categories, with certain subcategories containing
large proportions of foods classified as SFs or FFs. Categories containing the greatest
proportions of SFs included vegetable juices and drinks (9%), carbonated and non-carbonated
beverages and wine coolers (6%), and juices, nectars, and fruit drink substitutes (4%), while
categories containing the largest proportions of FFs included shakes and shake substitutes (36%),
yogurts (32%), grain-based bars (up to 31%), and ready-to-eat breakfast cereals (up to 25%).
The most commonly added micronutrients in SFs were B vitamins, caffeine, and taurine. In
many SFs, B vitamins were added in amounts several times the RDA of children and/or adults,
and in two cases, niacin/vitamin B1 were added in an amount exceeding the UL of both children
and adults. The highest levels of caffeine and taurine found in SFs were 360 ppm and 2000
mg/serving, respectively. The most commonly added functional ingredients in FFs included
novel fibres, such as inulin, and probiotic bacterial cultures. Other ingredients added to FFs
included herbals and bioactives such as ginseng extract, added proteins such as soy and whey
protein concentrates, novel ingredients such as plant sterols, and omega-3/omega-6 fatty acids
such as DHA oil.
Most SFs analyzed in the FLIP 2013 had median FSANZ NPSC scores meeting cut-offs to be
considered as ‘healthy’ foods. In addition, SFs were either healthier than or as equally healthy as
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non-SFs in the subcategories examined, when median NPSC scores were compared between the
two groups. For FFs, 4 out of 10 food subcategories analyzed had median nutrient profiling
scores that rated them as ‘less healthy’ foods, and would not be permitted to carry health claims
under the FSANZ model. In 3 out of these 4 subcategories, FFs were still significantly healthier
(i.e. had lower median NPSC scores) than non-FFs in these subcategories, despite being rated as
‘less healthy’ foods. This finding suggests that many FFs are found in food subcategories that
generally contain foods that are not considered healthy, such as cookies and wafers, and some
types of ready-to-eat breakfast cereals. This may negatively affect the dietary patterns of
consumers as studies have found that consumers are more likely to choose foods from unhealthy
food categories, such as sugary beverages and salty snacks, if they contain added nutrients (71).
FFs in remaining food subcategories (6 out of 10) had median NPSC scores signifying that they
were healthy.
Both SFs and FFs were more heavily marketed than foods without added supplemental or
functional ingredients in all food subcategories analyzed, regardless of nutritional quality. In
several subcategories, SFs and FFs contained a greater number of both government regulated
claims (i.e. nutrient content and health claims) and FOP claims, and in other subcategories they
carried either a larger number of government regulated claims or FOP claims, but not both.
Study 2
Over 900 prepackaged food products in the FLIP 2013 contained high levels (>25% DV) of
voluntarily added vitamins and minerals. A wide range of foods, including breakfast cereals,
plant-based beverages and milk-based drinks, and fruit juices, nectars, and fruit juice substitutes,
contained large proportions (as high as 77%) of foods with high levels of voluntary fortification
(VHVMs).
In addition, VHVMs were less healthy than foods without high levels of voluntary fortification
in 50% (4 out of 8) food subcategories, based on median FSANZ nutrient profiling scores. In two
of these subcategories—hot breakfast cereals and ready-to-eat breakfast cereals (puffed and
coated, without fruit or nuts, very high fibre)—VHVMs had nutrient profiling scores that were
considered unsatisfactory for carrying health claims under FSANZ, while non-VHVMs in these
subcategories were considered healthy enough to carry health claims. In the remaining food
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subcategories, both VHVMs and non-VHVMs had median nutrient profiling scores meeting cut-
offs to classify them as healthy foods.
Foods with high levels of voluntary fortification were more heavily marketed than foods without
high levels of voluntary fortification in all food subcategories analyzed, irrespective of
nutritional quality. In all but two subcategories, VHVMs had greater numbers of both
government regulated claims (i.e. nutrient content and health claims) and FOP systems and
symbols than non-VHVMs.
5.2 General discussion
The health problem that Canadians face today is very different than what they faced when
policies regarding the addition of nutrients to foods were first proposed. In the early 1900s,
diseases such as rickets, goitre, and beriberi were widespread in the Canadian population due to
the limited availability of foods naturally containing adequate levels of essential nutrients, such
as vitamins and minerals (8). As a result, the mandatory fortification of foods with vitamins,
minerals, amino acids, and other micronutrients was successfully introduced in the 1940s to
reduce the prevalence of deficiency-related diseases and curb nutrient inadequacy in the
population. Since then, regulations have been revised and new policies created to allow for a
greater variety of foods to contain added nutrients and to promote the emergence of new foods.
However, micronutrient inadequacy is no longer a pressing issue in Canada. In fact, most
Canadians today are facing the opposite problem, dealing with an excess of nutrients rather than
an insufficiency. The majority of Canadians have energy intakes that exceed their needs and
consume sodium in amounts that are above the UL, and a large proportion of Canadians have fat
intakes that are above the AMDR (94). Regulations permitting the sale of a wide variety of foods
containing high levels of added nutrients may put Canadians at risk of excess intakes of both
micronutrients, such as vitamins and minerals, and macronutrients, such as fat and sugar.
In terms of excess micronutrient intakes, the findings from the studies conducted in this thesis
show that a large proportion of SFs contain vitamins and minerals, such as B vitamins, that have
no evidence of inadequacy in the Canadian population (29), and that many SFs contain these
micronutrients in levels that are above the RDA and/or UL. In addition to containing high levels
of added vitamins and minerals, a large proportion (61%) of SFs contained very high levels of
80
caffeine (up to 360 ppm/serving) and the amino acid taurine (up to 2000 mg/serving). Although
maximum levels based on safety assessments have been established in Category Specific
Guidance Documents (18, 19) for the addition of caffeine and amino acids to certain foods such
as energy drinks, there is currently no established safe level of caffeine consumption for children
and adolescents. These population subgroups are at greater risk for developing serious adverse
effects associated with caffeine toxicity, such as heart palpitations, seizures, and death (79). SFs
containing high levels of caffeine are required to carry cautionary statements, such as ‘not
recommended for persons under 18 years of age’, on food labels (18). However, these products
are sold alongside other beverages and are easily accessible to all members of the population. In
addition, the effectiveness of cautionary labels in preventing inappropriate consumption of
caffeinated energy drinks in the Canadian population has not been examined, although one study
conducted in the US found that certain warning labels may be associated with decreased
consumption of energy drinks in adolescents (81). The consumption patterns of caffeinated
beverages among children and adolescents in the Canadian population is currently unknown,
although the number of cases of caffeine toxicity reported in these population subgroups
worldwide has been increasing (79).
Despite the fact that a large proportion of SFs were found to contain very high levels of added
substances, the overall prevalence of SFs in Canadian grocery stores is currently quite low; only
52 foods were classified as SFs in 2013. This may be due to tighter restrictions surrounding the
types of foods that are currently permitted to be supplemented, in comparison to the wide range
of foods that are permitted to contain functional ingredients or added micronutrients through
voluntary fortification. However, SFs are becoming increasingly popular, as the nutritionally-
enhanced food market is soaring in revenue worldwide (27), and may become more widely
distributed in the Canadian marketplace overtime.
Foods containing high levels of vitamins and minerals added through voluntary fortification are
much more prevalent than SFs, with over 900 prepackaged foods and beverages in the FLIP
2013 classified as VHVMs. Many food categories that are marketed to and consumed by all
members of the population and highly consumed by children and adolescents (90, 91), such as
breakfast cereals and fruit juices, nectars and fruit drink substitutes, contain large proportions (as
high as 77%) of foods that have been voluntarily fortified with high amounts (>25% DV) of
81
vitamins and minerals, such as vitamin C, thiamine, folic acid, and iron. A recent analysis
conducted in the US found that individuals, including children, with greater exposure to
voluntarily fortified foods were at higher risk of having micronutrient intakes above the UL (25).
The potential for voluntarily fortified foods to contribute to excess intakes amongst Canadians is
an even greater concern in individuals taking vitamin and mineral supplements. Findings from
the CCHS 2.2 showed that a large proportion (40%) of Canadians take some form of a
vitamin/mineral supplement, and that supplement use is associated with an increase in the
percentage of vitamin/mineral intakes greater than the UL amongst all sex/age groups (87). This
is particularly concerning in the case of folic acid, one of the most commonly added vitamins in
VHVMs, considering that 40% of Canadians have been found to have high folate status(92).
Unlike SFs and VHVMs, the FFs (n = 326) analyzed in this thesis generally did not contain
substances that may cause harm if taken in excess. Some commonly occurring functional
ingredients in these foods were novel fibres, such as inulin, and probiotics. Aside from certain
mild symptoms, such as bloating, these substances are generally not known to have adverse
effects when taken in high amounts. However, as FFs are gaining popularity and becoming more
widespread, it is important to keep track of the types of substances that are being added to these
foods over time.
The findings from this thesis support concerns that the consumption of nutritionally-enhanced
foods—in particular SFs and VHVMs—may significantly increase the likelihood of excess
micronutrient intake amongst individuals in the Canadian population, particularly in individuals
taking supplements and in subgroups that have lower nutrient requirements, such as children.
The potential health effects resulting from excess micronutrient intakes can be very serious. High
intakes of vitamins and minerals have been associated with a wide array of short-term and long-
term detrimental effects, ranging from nausea and flushing of the skin to increasing risk of
certain types of cancer (95) and promoting obesity (96); and excessive caffeine consumption
may to lead to adverse cardiovascular effects, seizures, and death, particularly in children and
adolescents (79). To appraise the extent to which foods with added nutrients may have the
potential to contribute to excessive nutrient intakes, a nationwide survey capturing brand names
of foods to determine the consumption of supplemented and voluntarily fortified foods in the
Canadian population and measure the micronutrient intakes of various population subgroups,
82
including children, is needed. If such a survey reveals an association between the consumption of
supplemented and voluntarily fortified foods and the risk of nutrient intakes about the UL, it may
be necessary for the Canadian government to re-evaluate its regulations surrounding the addition
of micronutrients to foods, such as lowering the levels of vitamins, minerals, caffeine, and amino
acids that are currently permitted to be added to supplemented foods and reducing the range of
foods that may be voluntarily fortified.
In addition to reassessing existing regulations, it is also important to inform and educate
consumers about the appropriate consumption of nutritionally-enhanced foods. Foods and
beverages containing added nutrients are referred to in different terms depending on the type and
amount of added substances they contain. However, to consumers, these foods are mostly
indistinguishable from conventional foods, as they currently lack a product identifier and are sold
side-by-side other foods in grocery stores. The NFt is the main source of information regarding
the micronutrient content of a food that consumers currently have access to on the food label.
However, studies have shown that the NFt does not fully enable Canadian consumers to make
healthy dietary choices (33), and that many consumers may not be using or accurately
understanding the NFt (97). In addition, as was shown here, foods with added nutrients are
heavily marketed, and the presence of multiple claims on a product label may add to consumer
confusion (98). The Canadian government should provide consumers with simple and easily
accessible tools that will allow consumers to identify nutritionally-enhanced foods and to make
informed food choices and prevent excessive or inappropriate consumption of these foods.
The addition of vitamins, minerals, bioactives, and other substances to a food may also cause
consumers to overlook the levels of other nutrients, such as sugar, fat, and sodium, present in the
food and potentially alter the eating habits of Canadians to include more unhealthy foods. A
Canada-wide survey found that the majority of consumers would increase their consumption of
foods of otherwise poor nutritional quality, such as salty snacks and fruit-flavoured drinks, if
they contained added vitamins and minerals, and that a large proportion of parents would provide
more of these foods to their children (71). In addition, focus group data found that Canadian
consumers perceived the fortification of unhealthy foods with vitamins and minerals as an
‘added bonus’ (72). International data has shown that the enrichment of foods with substances
such as bioactives is perceived as providing a greater health benefit when these substances are
83
added to foods recognized as ‘unhealthy’, such as spreads, compared to foods perceived as
‘healthy, such as yogurt (73).
Findings from Studies 1 and 2 revealed that many nutritionally-enhanced foods, particularly FFs
and VHVMs, would not be considered as ‘healthy’ foods according to the validated FSANZ
nutrient profiling model (1, 54, 57), due to having high levels of ‘negative’ nutrients—such as
saturated fat, sugar, and sodium—and/or low levels of ‘positive’ nutrients—such as protein,
fibre, and fruits/vegetables/nuts/legumes. The median scores of FFs in a large proportion of food
subcategories, such as cookies and wafers and some breakfast cereals, did not meet cut-offs to be
considered healthy. However, FFs were still scored as ‘more healthy’ or ‘equally healthy’ than
conventional foods without functional ingredients in these subcategories. This suggests that, in
many cases, functional ingredients are being added to foods in food categories that are generally
considered unhealthy. VHVMs, on the other hand, not only failed to meet score cut-offs to be
considered healthy, they were also significantly less healthy than non-VHVMs in several food
subcategories. This finding suggests that, in several cases, the addition of vitamins and minerals
to foods is made to the least healthy foods within a food category. SFs were the only types of
nutritionally-enhanced foods that met score cut-offs to be considered ‘healthy’ in both food
subcategories analyzed. This partly may be due to the fact that far fewer and a smaller range of
SFs were found in the FLIP 2013 compared to FFs and VHVMs.
Marketing analyses found that SFs, FFs, and VHVMs carried significantly greater numbers of
nutrition-related claims than foods without added nutrients in all food subcategories analyzed,
regardless of the nutritional quality of these foods. Foods with added nutrients in many food
subcategories had higher numbers of both government-regulated claims (i.e. nutrient content and
health claims) and FOP systems/symbols. Multiple studies have shown nutrition-related claims
positively affect consumer attitudes towards a food (41-44, 46), and that this effect is more likely
to occur if claims appear on products that are generally perceived as ‘less healthy’, such as
candies and spreads (47). In addition, a conjoint study specifically examining Danish, Finnish,
and American consumers’ perceptions of functional foods found that health claims appearing on
food labels had a positive effect on the perceived healthiness of functional foods (73). The
combined effects of adding vitamins, minerals, and substances to foods of low nutritional value
and heavy marketing on these products may have the potential to lead consumers to inadvertently
84
make unhealthy dietary choices and have significant negative impacts on the dietary patterns of
Canadians. To further investigate the issue, a mock-package experiment should be conducted to
evaluate consumer attitudes and decision making towards supplemented, functional, and
voluntarily fortified foods with various nutrient profiles and marketing levels.
Several countries, including the United Kingdom, Ireland, Australia, New Zealand, Denmark,
and Norway, have used nutrient profiling to either restrict the types of foods that may carry
health claims or regulate the marketing of foods to children to combat rising rates of obesity and
diet-related noncommunicable disease (NCDs) (1). Despite also facing these same health issues,
Canada currently does not use a nutrient profiling model to regulate the marketing of food
products, meaning that foods may carry various types of claims, such as nutrient content and
function claims, and FOP marketing on their labels, despite having poor nutritional quality. The
combined findings of this thesis and other studies (71, 72) support the need for Health Canada to
use a validated nutrient profiling system to limit the types of foods that may contain added
nutrients and restrict the types of marketing that may appear on these foods, since it was found
that: i) many foods with added nutrients, in particular FFs and VHVMs, have otherwise poor
nutritional value; and ii) that foods with added nutrients carry high numbers of nutrition-related
claims, despite the fact that a large proportion of them are unhealthy and/or less healthy than
conventional foods.
5.3 Conclusion
Since the initial introduction of mandatory fortification in the 1940s, policies surrounding the
addition of nutrients to foods in Canada have constantly been undergoing change. Traditionally,
nutrients such as vitamins and minerals have been added to foods for purposes such as reducing
the incidence of deficiency-related diseases or preventing the prevalence of inadequate nutrient
intakes in segments of the population. Today, however, there is an extensive range of
nutritionally-enhanced foods available to consumers, including voluntarily fortified foods,
supplemented foods, and functional foods, and they are a fast-growing sector of the food
industry, both within Canada and globally. The growth in the supplemented, functional, and
fortified food market has been largely attributed to an increase in health consciousness of
85
consumers and the desire to maintain or improve physical and mental well-being. However, this
thesis found that many nutritionally-enhanced foods, including supplemented foods, functional
foods, and foods with high levels of voluntary fortification, contain high levels of nutrients that
do not have evidence of inadequate intake in the Canadian population or are necessary to
maintain or improve health. In addition, a large proportion of these foods were found to have
poor nutrient profiles and contain high levels of marketing, regardless of their nutritional quality.
As the nutritionally-enhanced food market is growing and these foods become more widely
available to consumers, a number of issues regarding the consumption of foods with added
nutrients warrant attention, such as high intakes of nutrients that exceed ULs and the negative
shifting of dietary patterns to include more unhealthy foods. To further evaluate these concerns,
studies should be conducted to investigate consumer attitudes and decision-making towards SFs,
FFs, and VHVMs. The combined findings of such studies and this thesis can be used to inform
and aid the Canadian government in creating an appropriate regulatory framework for foods with
added nutrients and taking other measures, such as consumer education campaigns or product
specific labeling or logos to help consumers identify such products, to allow for the safe
consumption of these foods to protect the health and well-being of Canadians. In addition, the
prevalence and nature of foods with added nutrients in the Canadian marketplace should be
closely monitored over time to investigate any potential changes that may occur, particularly as a
large number of NHPs become recognized as foods (16), which were not captured in this study.
86
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Appendices
Appendix 1. Method for calculating FVNL content of foods using the Ingredients List
95
Appendix 2. Ingredients that can be added to nutritionally-enhanced foods*
Supplemented foods
Vitamins: Biotin, folic acid/folate, niacinamide/nicotinamide, nicotinic acid/niacin, pantothenic
acid/d-calcium pantothenate, riboflavin/vitamin B2, thiamine/vitamin B1, vitamin
A/retinol/retinyl palmitate/retinyl acetate/beta-carotene, vitamin
B12/cyanocobalamin/methylcobalamin, vitamin B6/pyridoxine, vitamin C/ascorbic acid/calcium
ascorbate, vitamin D/cholecalciferol/ergocalciferol, vitamin E/d/dl-alpha tocopherol/tocopheryl
acetate/tocopheryl succinate, and vitamin K.
Minerals: Boron, calcium, choline, chromium, copper, iodine, iron, magnesium, manganese,
molybdenum, phosphorous, potassium, selenium, and zinc.
Amino acids: Any group of amino acids (e.g. branched chain amino acids) or isolated amino
acids such as alanine, arginine, aspartic acid/asparagine, cysteine/cystine, glutamic
acid/glutamine, glycine, histidine, isoleuine, leucine, lysine, methionine, phenylalanine, proline,
serine, taurine, threonine, tryptophan, tyroisine, and valine.
Herbals/bioactives: caffeine.
Functional foods
Herbals/bioactives: Acai berry/fruit extract, aloe vera leaf (extract), alpha lipoic acid, amla
(extract), aquamin, ashwaganda (extract), astragulus root (extract), bee pollen, bilberry extract,
black cohosh (extract), black tea (extract), bladderwrack, burdock (extract),caffeine, cascara
sagrada, chamomile flower (extract), chasteberry (extract), chlorella, chondroitin sulfate,
citicholine, citrulline malate, coenzyme Q10, coffee bean extract, conjugated linoleic acid
(CLA), elderberry extract, damiana (extract), dandelion extract, dong quai, Echinacea
purpurea/angustifolia/pallida (extract), epimedium/horny goat weed extract, GABA (gamma
amino butyric acid), garcinia cambogia fruit extract/hydroxycitric acid, giant knotweed, ginger
extract, gingko biloba (extract), glucosamine sulfate or hydrochloride, N-acetylglucosamine, goji
berry extract, gotu kola (extract), grape seed/skin extract, grapefruit seed extract, green tea
extract, hibiscus (extract), guarana (extract), gymnema sylvestre leaf (extract), hawthorn, hoodia,
hops, horsetail/equisetum, houblon, kelp, kola nut, lavender (extract), lemon balm/Melissa
(extract), lemon verbena, linden, maca root, mangosteen extract, melatonin, milk thistle
(extract)/silybum/silymarin, MSM/methyl-sulfonyl-methane, noni, North American ginseng
(extract), Panax ginseng (extract)/Korean ginseng/Asian ginseng, passiflora (passionflower),
prickly pear extract, probiotic bacterial cultures, quercitin, raspberry seed extract, red wine
extract, resveratrol, rhodiola (extract), rosehip (extract), rosemary (extract), saw palmetto,
schizandra (extract), skullcap, seabuckthorn, senna, Siberian ginseng (extract)/Eleutherococcus,
spirulina, St. John’s wort, tilleul, uva ursi/bearberry, valerian (extract), vinpocetine, white tea
(extract), white willow bark (extract), yerba mate (extract), 5-hydroxytryptophan
Proteins: Casein, whey, soy, rice, pea protein as concentrates or isolates
96
Omega 3 or omega 6 fats: Fish oil, flax/rapeseed oil, types of fish oil (mackerel, anchovy,
sardine, krill, etc), borage oil, DHA oil, evening primrose oil
Novel fibres: acacia gum (gum arabic), barley bran, beta-glucan, corn bran, corn syrup (fibre),
fructooligosaccharides or oligofructose, galactooligosaccharides, high amylose corn starch,
inulin (from chicory root, Jerusalem artichoke tuber, or Blue agave head),
isomaltooligosaccharides, maltodextrin (fibre), modified wheat starch, oat bran, oat hull fibre,
partially hydrolyzed guar gum, pea hull fibre, polydextrose, polysaccharide complex
(glucomannan, xanthan gum, sodium alginate), psyllium seed husk, sieved barley meal, soy
cotyledon, sugar beet fibre, wheat flakes (starch reduced), wheat bran
Other novel ingredients: plant sterols, phytosterols
* This list was created in collaboration with Health Canada and was based on food ingredients
eligible for consideration for TMALs, as well as ingredients that were commonly found in foods in
FLIP 2013.
97
Appendix 3. List of all supplemented foods (SFs) and ingredients in the FLIP
2013
* RDA/AI/UL refers to highest requirements with the population, excluding pregnant and lactating women and individuals over
the age of 70.
Product Name Company Brand Added ingredient Amount per
serving/ppm
Exceeds
RDA/AI*
Exceeds
UL*
NOS Energy Drink The Coca-Cola
Company
NOS
Taurine 200 mg - -
Caffeine 360 ppm - -
L-theanine 25 mg - -
Vitamin B6 3.96 mg YES -
Vitamin B12 12 µg YES -
Charged Lime
Energy Drink
Coca-Cola
Refreshments
Canada Company
NOS Taurine 200 mg - -
Caffeine 360 ppm - -
L-theanine 25 mg - -
Vitamin B6 3.96 mg YES -
Vitamin B12 12 µg YES -
Super Sours - Green
Apple
Rockstar Inc Rockstar Taurine 2000 mg - -
Caffeine 338 ppm - -
Pantothenic acid 20.3 mg YES -
Niacin 39.1 mg YES YES
Vitamin B6 3.96 mg YES -
Vitamin B12 12 µg YES -
Super Sours –
Bubbleberry
Rockstar Inc Rockstar Taurine 2000 mg - -
Caffeine 338 ppm - -
Pantothenic acid 20.3 mg YES -
Niacin 39.1 mg YES YES
Vitamin B6 3.96 mg YES -
Vitamin B12 12 µg YES -
Energy Drink Red Bull Canada
Ltd.
Red Bull Taurine 1420 mg - -
Caffeine 320 ppm - -
Niacin 27.6 mg YES NO
Pantothenic acid 7 mg YES -
Vitamin B6 7.02 mg YES -
Vitamin B12 7.2 µg YES -
Total Zero Energy
Drink
Red Bull Canada
Ltd
Red Bull Taurine 1000 mg - -
Caffeine 320 ppm - -
Niacin 20.7 mg YES NO
Pantothenic acid 4.9 mg NO -
Vitamin B6 5.04 mg YES -
Vitamin B12 5.0 µg YES -
Sugar Free Energy
Drink
Red Bull Canada
Ltd
Red Bull Taurine 1420 mg - -
Caffeine 320 ppm - -
Niacin 27.6 mg YES NO
Pantothenic acid 7.0 mg YES -
Vitamin B6 7.02 mg YES -
Vitamin B12 7.2 µg YES -
98
Product Name Company Brand Added
ingredient
Amount per
serving/ppm
Exceeds
RDA/AI*
Exceeds
UL*
The Red Edition Red Bull Canada
Ltd
Red Bull Taurine 1000 mg - -
Caffeine 320 ppm - -
Niacin 20.7 mg YES NO
Pantothenic acid 4.9 mg NO -
Vitamin B6 5.04 mg YES -
Vitamin B12 5.0 µg YES -
The Silver Edition Red Bull Canada
Ltd
Red Bull Taurine 1000 mg - -
Caffeine 320 ppm - -
Niacin 20.7 mg YES NO
Pantothenic acid 4.9 mg NO -
Vitamin B6 5.04 mg YES -
Vitamin B12 5.0 µg YES -
The Blue Edition Red Bull Canada
Ltd
Red Bull Taurine 1000 mg - -
Caffeine 320 ppm - -
Niacin 20.7 mg YES NO
Pantothenic acid 4.9 mg NO -
Vitamin B6 5.04 mg YES -
Vitamin B12 5.0 µg YES -
Sugar Free NOS The Coca-Cola
Company
NOS Taurine 200 mg - -
Caffeine 360 ppm - -
Vitamin B6 3.96 mg YES -
Vitamin B12 12 µg YES -
Refreshers - Orange
Melon
Starbucks
Corporation
Starbucks Niacin 5.75 mg NO NO
Pantothenic acid 1.75 mg NO -
Vitamin B6 0.45 mg NO -
Sparkling Green
Coffee – Strawberry
Lemonade
Starbucks
Corporation
Starbucks Niacin 5.75 mg NO NO
Pantothenic acid 1.75 mg NO -
Vitamin B6 0.45 mg NO -
Sparkling Green
Coffee - Raspberry
Pomegranate
Starbucks
Corporation
Starbucks Niacin 5.75 mg NO NO
Pantothenic acid 1.75 mg NO -
Vitamin B6 0.45 mg NO -
Coconut Water All Market, Inc VITA
COCO
Vitamin C 60 mg NO NO
Mocha Cappuccino Bolthouse Juice
Products, LLC
Bolthouse
Farms
Vitamin C 96 mg YES NO
Calcium 330 mg NO NO
Vitamin B6 2.7 mg YES -
Zinc 3.6 mg NO NO
Vitamin B12 9 µg YES -
Pure Life Nature's
Blends Acai Grape
Flavour
Nestle Canada Inc Nestle Zinc 0.9 mg NO NO
Nature's Blends -
Tropical Citrus
Flavour
Nestle Waters
Canada
Nestle Pure
Life
Zinc 0.9 mg NO NO
Enhanced Fruit
Flavoured Water -
Orange Mango
Flavour
Nestle Waters
Canada
Nestle Zinc 0.9 mg NO NO
* RDA/AI/UL refers to highest requirements with the population, excluding pregnant and lactating women and individuals over
the age of 70.
99
Product Name Company Brand Added
ingredient
Amount per
serving/ppm
Exceeds
RDA/AI*
Exceeds
UL*
Fruit Zoo Strawberry
Banana
A. Lassonde Inc Oasis Thiamine 0.13 mg NO -
Folic acid 77 µg NO NO
Iron 1.4 mg NO NO
Grape Wild Berries
Cocktail
A. Lassonde Inc Oasis Thiamine 0.13 mg NO -
Folic acid 77 µg NO NO
Iron 1.4 mg NO NO
Fruit Zoo Apple Juice A. Lassonde Inc Oasis Calcium 88 mg NO NO
Vitamin D 16 IU NO NO
Wild Berry
Pomegranate Juice
A. Lassonde Inc Oasis Nutrisource Vitamin E 2 mg NO NO
Cranberry Juice – Low
Calorie
A. Lassonde Inc Oasis Nutrisource Vitamin E 2 mg NO NO
Cranberry Juice A. Lassonde Inc Oasis Nutrisource Vitamin E 2 mg NO NO
Pomegranate
Blueberry Juice
Beverage with
Vitamins
Tropicana
Products, Inc.
Tropicana
Trop50
Vitamin E 2.5 mg NO NO
Orange Some Pulp
Juice Beverage with
Vitamins
Tropicana
Products, Inc.
Tropicana
Trop50
Magnesium 25 mg NO NO
Thiamine 0.104 mg NO -
Riboflavin 0.096 mg NO -
Vitamin B6 0.108 mg NO -
Apple Juice Loblaws Inc. President Choice-
Blue Menu
Potassium 245 mg NO -
Iron 2.1 mg NO NO
Thiamine 0.195 mg NO -
Folic acid 132 mg NO NO
Strawberry Banana A. Lassonde Inc Oasis Fruit Zoo Potassium 350 mg NO -
Iron 2.1 mg NO NO
Thiamine 0.195 mg NO -
Folic acid 99 mg NO NO
Grape Wild Berries A. Lassonde Inc Oasis Fruit Zoo Potassium 245 mg NO -
Iron 1.4 mg NO NO
Thiamine 0.195 mg NO -
Folic acid 99 mg NO NO
100% Juice - Peach
Clementine
A. Lassonde Inc Oasis - Fruit Zoo Potassium 385 mg NO -
Iron 1.4 mg NO NO
Thiamine 0.195 mg NO -
Folic acid 99 mg NO NO
Pulp Free Orange
Juice
Loblaws Inc. President Choice-
Blue Menu
Thiamine 0.195 mg NO -
Folic acid 66 mg NO -
Trop50 No Pulp
Tropicana
Products, Inc.
Tropicana Magnesium 25 mg NO NO
Thiamine 0.104 mg NO -
Riboflavin 0.096 mg NO -
Vitamin B6 0.108 mg NO -
100
* RDA/AI/UL refers to highest requirements with the population, excluding pregnant and lactating women and
individuals over the age of 70.
Product Name Company Brand Added
ingredient
Amount per
serving/ppm
Exceeds
RDA/AI*
Exceeds
UL*
Trop50 Calcium And
Vitamin D
The Minute Maid
Company Canada
Inc
Tropicana Calcium 330 mg NO NO
Vitamin D 100 IU NO NO
Fruits&Vegetables
Apple-berry
Lassonde Industries
Inc
Oasis Health
Break
Vitamin E 2 mg NO NO
Orange Juice - 100%
Pure - with calcium &
vitamin D
Canada Safeway
Limited
Safeway
Select
Calcium 330 mg NO NO
Vitamin D 120 IU NO NO
100% Pure & Natural
Orange Juice With
Added Calcium And
Vitamin D - no pulp
Tropicana Products,
Inc.
Tropicana
Essentials
Calcium 330 mg NO NO
Vitamin D 100 IU NO NO
Orange Juice With
Added Calcium And
Vitamin D
Loblaws Inc.
President
Choice-Blue
Menu
Calcium 330 mg NO NO
Vitamin D 100 IU NO NO
100% Apple juice A. Lassonde Inc Oasis
Classic
Calcium 110 mg NO NO
Vitamin D 20 IU NO NO
Orange Juice Metro Brand Irresistibles -
life smart
Calcium 330 mg NO NO
Vitamin D 100 IU NO NO
Minutes Maid
Calcium And Vitamin
D 100% Orange Juice
Frozen Concentrate
The Minute Maid
Company Canada
Inc
Minute Maid
Calcium 330 mg NO NO
Vitamin D 100 IU NO NO
Simply Orange
Calcium
The Minute Maid
Company Canada
Inc
Simply
Orange
Calcium 330 mg NO NO
100% pure & natural
orange juice with
added calcium +
Vitamin D
Tropicana Products,
Inc.
Tropicana
Essentials
Calcium 330 mg NO NO
Vitamin D 100 IU NO NO
Cheddar Style
Flavour
Galaxy Nutritional
Foods
Veggie Vitamin A 300 RE NO NO
Vitamin B12 1.5 µg NO -
Vitamin D 100 IU NO NO
Folic acid 99 µg NO NO
Vitamin B6 0.54 mg NO -
Vitamin E 7.5 mg NO NO
Italian Flavour Galaxy Nutritional
Foods
Veggie Vitamin A 300 RE NO NO
Vitamin B12 1.5 µg NO -
Vitamin D 100 IU NO NO
Folic acid 99 µg NO NO
Vitamin B6 0.54 mg NO -
Vitamin E 7.5 mg NO NO
101
Product Name Company Brand Added
ingredient
Amount per
serving/ppm
Exceeds
RDA/AI*
Exceeds
UL*
Malt Drink Mix -
Chocolate
AB Food and
Beverages
(Thailand) Ltd
Ovaltine
Vitamin C 15 mg NO NO
Vitamin A 250 RE NO NO
Iron 2.8 mg NO NO
Niacin 4.6 mg NO NO
Ovaltine - Classic Nestle Canada Inc. Ovaltine Vitamin C 18 mg NO NO
Vitamin A 250 RE NO NO
Iron 3.5 mg NO NO
Niacin 3.45 mg NO NO
Thiamine 0.325 mg NO -
Gluten-Free Corn &
Rice Flakes
Glutino Foods Glutino Vitamin E 7 mg NO NO
Vitamin B6 0.72 mg NO -
Folic acid 154 µg NO NO
Vitamin B12 3.2 µg YES -
V8 Low-Sodium
Vegetable Cocktail
Campbell Company
of Canada
V8 Potassium 840 mg NO -
Garden Cocktail -
Original Low Sodium
Canada Dry Mott's
Inc.
Mott's Potassium 700 mg NO -
Garden Cocktail
Low-Sodium
Canada Dry Mott's
Inc.
Mott's Potassium 455 mg NO -
Low-Sodium
Vegetable Cocktail
Campbell Company
of Canada
V8 – V
Fusion
Potassium 525 mg NO -
* RDA/AI/UL refers to highest requirements with the population, excluding pregnant and lactating women and
individuals over the age of 70.
102
Appendix 4. Standardized method used to calculate FSANZ nutrient profiling
score (NPSC) using data in the Canadian FLIP 2013 database
Step 1: Classify food into NPSC category
Category 1: Beverages
Category 2: Foods not included in Categories 1 or 3
Category 3: Cheese (with calcium content >320 mg/100 g), edible oil, edible oil spreads,
margarine, butter
Step 2: Calculate baseline points for average nutrient content/100 g or 100 mL
0 – 10 points for energy (kJ)
0 – 30 points for saturated fat (g)
0 – 10 points for total sugars (g)
0 – 30 points for sodium (mg)
Total baseline points = (energy points) + (saturated fat points) + (total sugars points) + (sodium
points)
Step 3: Calculate points for fibre (F), protein (P), and fruit/vegetable/nut/legume content (V) per
100 g or 100 mL
0 – 5 points for fibre (g)
0 – 5 points for protein (g)
0 – 5 points for fruit/vegetable/nut/legume (%)
Final score = Total baseline points – F points – P points – V points
Component of NPSC Information Available from Canadian Food
Labels
Energy (kJ/100 g or 100 mL) From Nutrition Facts table (NFt)
● kcal values converted to kJ
Saturated Fat (g/100 g or 100 mL) From Nutrition Facts table (NFt)
Total sugars (g/100 g or 100 mL) From Nutrition Facts table (NFt)
Sodium (mg/100 g or 100 mL) From Nutrition Facts table (NFt)
Fibre (g/100 g or 100 mL) From Nutrition Facts table (NFt)
Protein (g/100 g or 100 mL) From Nutrition Facts table (NFt)
Fruit/vegetable/nut/legume (FVNL) (%) Not available
● FVNL content estimated from rank of FVNL
ingredients in Ingredients List (see Appendix 1
for method of calculation in FLIP 2013)