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Szabó É, Csölle I, Felső R, Kuellenberg de Gaudry D, Nyakundi PN, Ibrahim K, Metzendorf MI, Ferenci T, Lohner S. Benefits and Harms of Edible Vegetable Oils and Fats Fortified with Vitamins A and D as a Public Health Intervention in the General Population: A Systematic Review of Interventions. Nutrients 2023; 15:5135. [PMID: 38140394 PMCID: PMC10745565 DOI: 10.3390/nu15245135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 12/12/2023] [Accepted: 12/14/2023] [Indexed: 12/24/2023] Open
Abstract
This systematic review aims to assess whether edible vegetable oils and fats fortified with vitamin A and/or D are effective and safe in improving vitamin intake and ameliorating deficiency states in the general population. In November 2022, we systematically searched MEDLINE, Cochrane CENTRAL, Scopus, Global Index Medicus, ClinicalTrials.gov, and WHO ICTRP (International Clinical Trials Registry Platform) for randomized controlled trials (RCT) and non-randomized studies of interventions (NRSI) investigating the fortification of edible vegetable oils and fats with either vitamin A or vitamin D or both as compared to the same vegetable oils and/or fats without vitamin A and D fortification or no interventions, in the general population, without age restriction. We assessed the methodological quality of included RCTs using Cochrane's risk of bias tool 2.0 and of NRSIs using ROBINS-I tool. We performed random-effects meta-analysis and assessed certainty of evidence using GRADE. We included eight studies. Available evidence showed no significant effect of fortification with vitamin A on serum retinol levels (RCTs: MD 0.35 µmol/L, 95% CI -0.43 to 1.12; two trials; 514 participants; low-certainty evidence; CCTs: MD 0.31 µmol/L, 95% CI -0.18 to 0.80; two trials; 205 participants; very low-certainty evidence) and on subclinical vitamin A deficiency. Low-certainty evidence showed no effect of vitamin D fortification on serum 25-hydroxy vitamin D concentration (MD 6.59 nmol/L, 95% CI -6.89 to 20.07; one trial; 62 participants). In conclusion, vitamin A-fortified vegetable oils and fats may result in little to no difference in serum retinol levels in general populations. The dose of vitamin A used in the trials may be safe but may not be sufficient to reduce subclinical vitamin A deficiency. Further, the evidence suggests that vitamin D fortification results in little to no difference in serum 25-hydroxy vitamin D concentration. Several aspects of providing fortified oils and fats to the general population as a public health intervention should be further investigated, including optimal fortification dose, effects on vitamin D deficiency and its clinical symptoms and potential adverse effects.
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Affiliation(s)
- Éva Szabó
- Cochrane Hungary, Clinical Centre of the University of Pécs, Medical School, University of Pécs, 7623 Pécs, Hungary; (É.S.); (I.C.); (R.F.); (D.K.d.G.)
- Department of Biochemistry and Medical Chemistry, Medical School, University of Pécs, 7624 Pécs, Hungary
| | - Ildikó Csölle
- Cochrane Hungary, Clinical Centre of the University of Pécs, Medical School, University of Pécs, 7623 Pécs, Hungary; (É.S.); (I.C.); (R.F.); (D.K.d.G.)
- National Laboratory for Human Reproduction, University of Pécs, 7624 Pécs, Hungary
- Doctoral School of Health Sciences, Faculty of Health Sciences, University of Pécs, 7621 Pécs, Hungary;
| | - Regina Felső
- Cochrane Hungary, Clinical Centre of the University of Pécs, Medical School, University of Pécs, 7623 Pécs, Hungary; (É.S.); (I.C.); (R.F.); (D.K.d.G.)
- National Laboratory for Human Reproduction, University of Pécs, 7624 Pécs, Hungary
- Genomics and Bioinformatics Core Facility, Szentágothai Research Centre, University of Pécs, 7624 Pécs, Hungary
| | - Daniela Kuellenberg de Gaudry
- Cochrane Hungary, Clinical Centre of the University of Pécs, Medical School, University of Pécs, 7623 Pécs, Hungary; (É.S.); (I.C.); (R.F.); (D.K.d.G.)
| | - Patrick Nyamemba Nyakundi
- Doctoral School of Health Sciences, Faculty of Health Sciences, University of Pécs, 7621 Pécs, Hungary;
- Department of Public Health Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary;
| | - Kazahyet Ibrahim
- Department of Public Health Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary;
| | - Maria-Inti Metzendorf
- Institute of General Practice, Medical Faculty of the Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany;
| | - Tamás Ferenci
- Physiological Controls Research Center, Obuda University, 1034 Budapest, Hungary;
- Department of Statistics, Corvinus University of Budapest, 1093 Budapest, Hungary
| | - Szimonetta Lohner
- Cochrane Hungary, Clinical Centre of the University of Pécs, Medical School, University of Pécs, 7623 Pécs, Hungary; (É.S.); (I.C.); (R.F.); (D.K.d.G.)
- Department of Public Health Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary;
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Händel MN, Jacobsen R, Thorsteinsdottir F, Keller AC, Stougaard M, Jensen CB, Moos C, Duus KS, Jensen A, Schiøler Kesmodel U, Abrahamsen B, Heitmann BL. Assessing Health Consequences of Vitamin D Fortification Utilizing a Societal Experiment Design: Methodological Lessons Learned from the D-Tect Project. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:8136. [PMID: 34360427 PMCID: PMC8345774 DOI: 10.3390/ijerph18158136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 07/16/2021] [Accepted: 07/23/2021] [Indexed: 11/16/2022]
Abstract
By utilizing historical changes in Danish legislation related to mandatory vitamin D fortification of margarine, which was implemented in the mid 1930s and abruptly abandoned in June 1985, the studies in the D-tect project investigated the effects of vitamin D on health outcomes in individuals, who during gestation were exposed or unexposed to extra vitamin D from fortified margarine. This paper reviews and narratively summarizes the analytic approaches alongside the results of the societal fortification experiment studies from the D-tect project and addresses the challenges in designing societal experiment studies and evaluating their results. The latter are discussed as lessons learned that may be useful for designers of similar studies, expected to be extensively utilized while researching the health consequences of the COVID-19 pandemic by comparing individuals born before and after the epidemic. In the D-tect project, 16 articles based on the societal fortification experiment were published analyzing 10 different outcomes and using different statistical approaches. Lessons learned included the detail of the analysis of the historical information on the exposure, availability and validity of the outcome data, variety of analytical approaches, and specifics concerning vitamin D effect evaluation, such as consideration of the influence of sunshine or season. In conclusion, the D-tect project clearly demonstrated the cost-effectiveness and research potential of natural- or societal-experiment-based studies.
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Affiliation(s)
- Mina Nicole Händel
- Research Unit for Dietary Studies, The Parker Institute, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark; (F.T.); (C.M.); (K.S.D.); (B.L.H.)
| | - Ramune Jacobsen
- Department of Pharmacy, University of Copenhagen, 2100 Copenhagen, Denmark;
| | - Fanney Thorsteinsdottir
- Research Unit for Dietary Studies, The Parker Institute, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark; (F.T.); (C.M.); (K.S.D.); (B.L.H.)
| | - Amélie Cléo Keller
- Department of Public Health, University of Copenhagen, 1014 Copenhagen, Denmark;
| | - Maria Stougaard
- Center for Early Intervention and Family Studies, Department of Psychology, University of Copenhagen, 1353 Copenhagen, Denmark;
| | - Camilla Bjørn Jensen
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark;
| | - Caroline Moos
- Research Unit for Dietary Studies, The Parker Institute, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark; (F.T.); (C.M.); (K.S.D.); (B.L.H.)
| | - Katrine Sidenius Duus
- Research Unit for Dietary Studies, The Parker Institute, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark; (F.T.); (C.M.); (K.S.D.); (B.L.H.)
| | - Allan Jensen
- Lifestyle, Reproduction and Cancer, Danish Cancer Society Research Center, 2100 Copenhagen, Denmark;
| | - Ulrik Schiøler Kesmodel
- Department of Obstetrics and Gynaecology, Aalborg University Hospital and Aalborg University, 9000 Aalborg, Denmark;
| | - Bo Abrahamsen
- Open Patient Explorative Network, Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark;
- Department of Medicine, Holbæk Hospital, 4300 Holbæk, Denmark
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7FY, UK
| | - Berit Lilienthal Heitmann
- Research Unit for Dietary Studies, The Parker Institute, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark; (F.T.); (C.M.); (K.S.D.); (B.L.H.)
- Department of Public Health, University of Copenhagen, 1014 Copenhagen, Denmark;
- The Boden Institute of Obesity, Nutrition, Exercise & Eating Disorders, University of Sydney, Sydney, NSW 2006, Australia
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Prenatal exposure to vitamin-D from fortified margarine and milk and body size at age 7 years. Eur J Clin Nutr 2015; 69:1169-75. [PMID: 25852027 DOI: 10.1038/ejcn.2015.55] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 02/17/2015] [Accepted: 03/05/2015] [Indexed: 11/08/2022]
Abstract
BACKGROUND/OBJECTIVES Prenatal vitamin-D deficiency may be associated with increased risk of obesity later in life. Using two national vitamin-D fortification programs as the setting for a societal experiment, we investigated whether exposure to vitamin-D from fortified margarine and low-fat milk during foetal life was associated with body size at 7 years of age. SUBJECTS/METHODS Vitamin-D fortification of margarine was mandatory in Denmark from 1961 to 1985, and voluntary fortification of low-fat milk was permitted from 1972 to 1976. Using information on body mass index (BMI) Z-score at the age of 7 years of 54,270 children, who were measured during the mandatory Copenhagen School Health examination, we compared children according to whether the mothers were pregnant during the fortification programs or not. The comparisons were performed for children born just before and after initiation or termination of margarine and milk fortification periods, respectively. In total four sets of analyses were performed. RESULTS We observed no difference in mean BMI Z-score between children exposed to vitamin-D fortification in utero and non-exposed children. Similar results were observed for overweight and obesity. CONCLUSIONS Prenatal exposure to vitamin-D from fortification of margarine and low-fat milk showed no association with body size at 7 years.
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