Pills and fortified foods: pseudo-solutions in a more sustainable diet

Abstract

In most Western countries, eating more sustainably means a diet with more plant-based and fewer animal-based products. But this compromises the intake of certain nutrients. Does the solution lie in food supplements and fortified foods? Or is the reality more complicated, and this solution insufficient? Twitter: @StephanPetersNL

Full text

Food supplements and fortified foods
REPORTAGE
Pills and fortified foods:
pseudo-solutions in a
more sustainable diet
In most Western countries, eating more sustainably means a diet
with more plant-based and fewer animal-based products. But this
compromises the intake of certain nutrients. Does the solution lie
in food supplements and fortified foods? Or is the reality more
complicated, and this solution insufficient?
TEXT DR. STEPHAN PETERS AND JOLANDE VALKENBURG (DUTCH DAIRY ASSOCIATION)
1
This article was published in Dutch in Voeding Magazine 1
|
2023

In formulating dietary guidelines
in the Netherlands, the policy is to
endeavor to get all nutrients through
food (see box on the Netherlands
Nutrition Centre). Supplements are
only recommended if this is actually
not feasible through food. Therefore, in
the Netherlands, such recommendations
are exceptions to the rule. There are a few
ocial food supplement recommendations
in the Netherlands. These concern folic
acid for women who want to become
pregnant or are pregnant, vitamin D
supplements for specific age groups and
people with darker skin tones, and vitamin
B12 supplements for vegans.
Protein transition
Making our food system more sustainable
by promoting more plant-based products
has led to nutrient supply becoming an
important issue. In developing the National
Climate Agreement, the Dutch government
has set the goal of a protein transition from
the (current) consumption of 60% animal
and 40% plant protein to 40% animal and
60% plant protein. In a recent report,
the Netherlands Nutrition Centre
(Voedingscentrum) and the National
Institute for Public Health and Environment
(RIVM) calculated the protein ratio if you
eat according to the Wheel of Five. The ratio
of plant to animal protein in the Wheel of
Five is about 50/50. When determining
the Wheel of Five, the Nutrition Centre
makes meticulous trade -os so as not to
compromise nutrient intake. In light of
this, the Netherlands Nutrition Centre and
the Health Council of the Netherlands
indicate that eating according to a ratio
of 40/60 animal/plant protein is possible
by decreasing or deleting meat intake
provided it is done with sucient attention
to the nutrients. It is not clear whether
this ratio is feasible for vulnerable groups,
such as the elderly and young children1.
More insight is therefore needed.
Tackling deficiencies
Generally speaking, in the West, it is
healthier and more sustainable to eat
more plant-based foods. Any far-reaching
transition, however, puts the intake of
specific nutrients in question. It can be
tempting to fill the gap with food supple-
ments and fortified products. To know
whether supplements and fortification
are the solution in preventing nutrient
deficiencies, it is necessary to examine
what this looks like in practice. Compliance
(i.e. adherence) to nutritional advice is
an important factor to consider when
implementing food supplement recom-
mendations or advising fortified products
in a more plant-based diet.
Adhering to supplement
advice
When policymakers consider food
supplement recommendations, it is
important to know the extent to which
population groups will adhere to the
advice. To do this, we can take a close
look at the groups that currently receive
food supplement recommendations.
Folic acid
The group where the highest compliance
to food supplement recommendations
can be expected is women who want to
become pregnant or who are pregnant.
They are advised to take a dietary supple-
ment of 400 micrograms of folic acid per
day. Adherence (i.e. compliance) among
this group is high, thanks to individual
counseling from midwifery practices
during this period. 55% use folic acid as
directed, 34% do not use it as directed,
and only 1.5% do not use folic acid
supplements. Among the group that does
not use it as directed, the main reasons are
starting too late and stopping too early.
This is particularly true among young
women who are undereducated, women
born abroad, or women who are becoming
pregnant for the first time2.
Vitamin B12
Another health-conscious group subject
to a food supplement recommendation
are vegans who should take vitamin B12
Wheel of Five,
Netherlands Nutrition Centre
The Dutch food-based dietary guidelines are based on a two-step process.
The scientific part is carried out by The Health Council of the Netherlands.
The Health Council has established the Dutch food-based dietary guidelines
in 2015, based on the health effects of whole foods on non-communicable
diseases. In addition, the Health Council has set the nutrition standards
to indicate how many nutrients people need for physiological processes
to run normally and for staying healthy. The second step is carried out
by The Netherlands Nutrition Centre that is responsible for translating
the Health Council's scientific advice into daily practical guidelines for
consumers. In doing so, we integrate the health effects of foods with
nutrition standards. To meet the need (i.e. norms) for energy and nutrients,
we mainly advise eating foods with a positive health effect or nutrient-rich
foods. The Dutch food-based dietary guidelines are called The Wheel of Five:
“We recommend supplements only if the nutrient recommendations cannot
be met through a healthy diet. Within the framework of a healthy diet,
we have included sustainability aspects. We have introduced restrictions in
the optimization process for products with high greenhouse gas emissions,
and offer actionable options through our website.”
In the Wheel of Five, the ratio of plant
to animal protein is about 50/50
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supplements. Compliance levels among this
group are not available in the Netherlands
but have been studied in Australia. That
study shows that about 90% of Australian
vegans take a vitamin B12 supplement3.
Vitamin D
One food supplement recommendation
that has been in place in the Netherlands
for decades is vitamin D. This recommen-
dation applies to various population
groups, such as women over 50 and men
over 70. The Dutch Food Consumption
Survey (VCP 2019-2021) shows that only
37% of women and 25% of men adhere
to this advice. These percentages have
not changed since the 2013 Food
Consumption Survey.
Compliance
It can be concluded that food supplement
compliance is high among health-conscious
people, such as folic acid among women
who want to become pregnant and vitamin
B12 among vegans. Compliance to general
supplement advice is low. In the case of
vitamin D for the elderly, which has been
in place for decades, it appears that only
a quarter to a third of the population can
adhere to the recommendation.
Consumer compliance to food supplement
recommendations depends on many
factors, including personal motivation,
eective communication, and implementing
such advice as directed. Only when intrinsic
motivation is high, such as in the case of
an (upcoming) pregnancy, is compliance
high. In addition, it is important to realize
that the group of Dutch people who
currently do not use dietary supplements
is 43%. They are not accustomed to using
supplements.
Food supplements and health
Because of the food matrix, nutrients in
the form of supplements can have a
dierent health eect than those found
in food. The Health Council's food-based
dietary guidelines (the "RGV") provide
several examples of this. For example,
the RGV concludes that dairy intake
has a protective eect on the risk of
type 2 diabetes and colorectal cancer.
The protective eect of dairy on colorectal
cancer is also observed when people take
calcium supplements. According to the
guidelines, there is no evidence that dairy
intake is associated with an increase in
cardio vascular disease, despite the fact
that dairy products contain saturated fat
and, in the case of cheese, salt. Intake of
calcium in supplement form, however, is
associated with a 30% increase in the risk
of coronary heart disease4. Hence, one
cannot necessarily assume that nutrients
from food supplements have the same
health eects as those within the food
matrix.
Fortified foods
What does the oering of fortified foods
look like in practice? Several plant-based
products can be found in the supermarket
that advertise themselves as an "alternative"
to an animal product. Many of these
products resemble animal products on the
surface, but not in their composition. This
assortment is getting wider. For example,
there are currently several plant-based
drinks on the market that oer themselves
as alternatives to milk. The base of these
drinks is often soy, pea, oat, almond,
coconut, or rice.
Guidelines for alternatives
The Netherlands Nutrition Centre has
published nutritional guidelines for the
composition of products that position
themselves as alternatives to animal
products. For example, there are
Supplement compliance: high among
health-conscious people, low among
the general population
Food supplements and fortified foods
REPORTAGE
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guidelines for plant-based drinks so that
people who do not want to or cannot
drink milk have a complete alternative.
Plant- based drinks as an alternative to
milk must contain at least 20% protein
and at least 0.24 micrograms of vitamin
B12 and 80 mg of calcium. There are also
limits of 1.1 grams of saturated fat, 6 grams
of sugar, and 0.15 grams of salt per 100 ml.
It is well-known that the protein quality
of plant-based drinks is inferior to that of
milk, except in the case of soy.
Product offering
In recommending fortified products, it is
important to know what percentage of
plant-based products meet the Nutrition
Centre's criteria. Organic plant-based
beverages are not permitted to be fortified
and do not meet the guidelines5.
Of all plant-based drinks, 50% appear to
be fortified with calcium, and some are
also fortified with vitamins. This means
that a small minority of plant-based drinks
meets the Nutrition Centre's criteria. Some
fortified soy drinks are the only product
that is an alternative to milk, according
to the Netherlands Nutrition Centre.
The market for plant-based drinks has
expanded considerably in recent years.
Soy drinks have faced a lot of competition
from other plant-based drinks, especially
oat drinks. Oat drinks are nutritionally
inferior to fortified soy drinks. Health
recommendations around fortified
products must take into account that
consumers often do not choose the
"desirable or healthy" alternatives.
Veggie burgers
Plant products that position themselves
as alternatives to meat and cheese are also
subject to the Nutrition Centre's criteria.
Most products in the supermarket do not
meet these criteria. Recent research by
the Dutch consumers' association The
Consumentenbond into veggie burgers
– where minced meat is replaced by, for
example, beans, nuts, tofu, or mushrooms
– shows that two-thirds are not healthy.
Veggie burgers contain too much salt and
saturated fat. The same research shows
that in the assortment at supermarkets,
a small number of veggie burgers contain
sucient protein, iron, and vitamin B126.
Summary
For a more plant-based diet, fortified plant
products and food supplements can be
considered in tackling deficiencies. It is
dicult to predict what consumers will
eat and drink. Taste and price remain the
main drivers. In practice, food supplements
and fortification are shown to be insucient
solutions. The reasons are that food
supplement recommendations for the
general public are not well followed, that
replacing animal products with plant
products does not entail a 1-to-1 nutrient
balance, and that consumers do not neces-
sarily make the switch to these products.
For example, even if consumers replace
milk with fortified plant-based beverages
that meet the criteria, this does not mean
a 1-to-1 replacement of the nutrients from
milk. Research shows that the availability
of vitamins A and B12, thiamine, zinc,
calcium iron, and iodine, among others,
becomes problematic7, 8. The assumption
that replacing animal products with
supplements and fortified plant products
can form an equally healthy diet, is not
correct. Not even if animal products are
replaced in the manner recommended by
the Netherlands Nutrition Centre.
Conclusion
For Western countries, it is healthier and
more sustainable to eat more plant-based
foods than in the current average diet.
Fortification and supplements do not
appear to be solutions to deficiencies that
may arise in the process. A diet that does
not provide all nutrients is not healthy
and is therefore not sustainable. In the
Netherlands, it has always been the policy
to provide all the nutrients people need
through food, unless there is no other way.
The Wheel of Five is a good example of
this. Health always comes first here.
Adhering to the Dutch Health Council
and the Netherlands Nutrition Centre's
requirements for healthy food is essential.
The Wheel of Five meets the food-based
dietary guidelines from the Health Council
and all the nutritional requirements for
vitamins, minerals, and trace elements
that we need. If the Dutch population
adheres to this, then their diets will be
healthy and more sustainable.
Organic
plant-based
drinks are not
allowed to be
fortified
References
1 RIVM, V. e., Source text Naar een meer plantaardig voedingspatroon. 2019, 2nd revised edition.
2 Passier A, W. P., Vorstenbosch S., Onderzoek Moeders van Morgen: gebruik foliumzuur volgens voorschrift rondom
zwangerschap blijft een aandachtspunt. Nederlands Platform voor Farmaceutisch Onderzoek. 2021;6:a1742.
2021.
3 Fuschlberger, M.; Putz, P., Vitamin B12 supplementation and health behavior of Austrian vegans:
a cross-sectional online survey. Sci Rep 2023, 13 (1), 3983.
4 Health Council of the Netherlands, Richtlijnen goede voeding; 2015.
5 Singh-Povel, C. M.; van Gool, M. P.; Gual Rojas, A. P.; Bragt, M. C. E.; Kleinnijenhuis, A. J.; Hettinga, K. A.,
Nutritional content, protein quantity, protein quality and carbon footprint of plant-based drinks and
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6 https://www.consumentenbond.nl/voedingstests/keuzehulp-vegaburgers
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with less meat and dairy nutritionally adequate? Public Health Nutr 2017, 20 (11), 2050-2062.
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Nutrients 2023, 15, 1825.
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