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Fortified Foods Are Major Contributors to Nutrient Intakes in Diets of US Children and Adolescents

Open AccessPublished:January 24, 2014DOI:https://doi.org/10.1016/j.jand.2013.10.012

      Abstract

      Background

      Even in an era of obesity and dietary excess, numerous shortfall micronutrients have been identified in the diets of US children and adolescents. To help tailor strategies for meeting recommendations, it is important to know what foods contribute greatly to micronutrient intakes. Data are lacking on specific contributions made by added nutrients.

      Objective

      Our aims were to examine the impact of fortification on nutrient adequacy and excess among US children and adolescents and to rank food sources of added nutrient intake and compare rankings with those based on total nutrient intake from foods.

      Design and statistical analyses

      Data were from 7,250 respondents 2 to 18 years old in the National Health and Nutrition Examination Survey 2003-2006. Datasets were developed that distinguished nutrient sources: intrinsic nutrients in foods; added nutrients in foods; foods (intrinsic plus added nutrients); and total diet (foods plus supplements). The National Cancer Institute method was used to determine usual intakes of micronutrients by source. The impact of fortification on the percentages of children having intakes less than the Estimated Average Requirement and more than the Upper Tolerable Intake Level was assessed by comparing intakes from intrinsic nutrients to intakes from intrinsic plus added nutrients. Specific food sources of micronutrients were determined as sample-weighted mean intakes of total and added nutrients contributed from 56 food groupings. The percentage of intake from each grouping was determined separately for total and added nutrients.

      Results

      Without added nutrients, a high percentage of all children/adolescents had inadequate intakes of numerous micronutrients, with the greatest inadequacy among older girls. Fortification reduced the percentage less than the Estimated Average Requirement for many, although not all, micronutrients without resulting in excessive intakes. Data demonstrated the powerful influence of fortification on food-source rankings.

      Conclusions

      Knowledge about nutrient intakes and sources can help put dietary advice into a practical context. Continued monitoring of top food sources of nutrients and nutrient contributions from fortification will be important.

      Keywords

      Even in the context of epidemic obesity and dietary excess, numerous shortfall micronutrients have been identified in American diets, including some vitamins and minerals of particular concern for children and adolescents.

      Dietary Guidelines Advisory Committee. Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2010, to the Secretary of Agriculture and the Secretary of Health and Human Services. Washington, DC: US Department of Agriculture, Agricultural Research Service. http://www.cnpp.usda.gov/DGAs2010-DGACReport.htm. Accessed March 16, 2012.

      To help tailor strategies for meeting nutrient recommendations, it is valuable to know what specific foods contribute greatly to micronutrient intakes. Important sources of nutrients in American diets are not necessarily foods that are intrinsically nutrient rich; nutrients can also come from dietary supplements or from foods that are frequently consumed and/or fortified.
      • Subar A.F.
      • Krebs-Smith S.M.
      • Cook A.
      • Kahle L.L.
      Dietary sources of nutrients among US children, 1989 to 1991.
      • Cotton P.A.
      • Subar A.F.
      • Friday J.E.
      • Cook A.
      Dietary sources of nutrients among US adults, 1989 to 1991.
      Fortification (this term is used generically throughout this article to refer to any addition of nutrients to foods) is one potential means of addressing micronutrient shortfalls. In fact, micronutrients have been added to fortify foods in the United States for more than half a century, and the practice played a major role in virtually eliminating classical nutrient-deficiency diseases, such as rickets and pellagra.
      • Backstrand J.R.
      The history and future of food fortification in the United States: A public health perspective.
      At the present time, some fortification is carried out in accordance with specific requirements of the US Food and Drug Administration, such as standards of identity for enriched grain foods or addition of vitamin A to reduced-fat milk to meet nutritional equivalency of whole milk, and other fortification has been termed discretionary
      Committee on the Use of Dietary Reference Intakes in Nutrition Labeling, Food and Nutrition Board, Institute of Medicine
      Dietary Reference Intakes: Guiding Principles for Nutrition Labeling and Fortification.
      because it is done voluntarily and at the discretion of food manufacturers (although, of course, within technological, regulatory, and other constraints). Despite its historical success, fortification has come under scrutiny because of concerns that it could lead to overconsumption of nutrients.
      • Backstrand J.R.
      The history and future of food fortification in the United States: A public health perspective.
      Committee on the Use of Dietary Reference Intakes in Nutrition Labeling, Food and Nutrition Board, Institute of Medicine
      Dietary Reference Intakes: Guiding Principles for Nutrition Labeling and Fortification.
      However, although fortification has undoubtedly increased vitamin and mineral intakes in the United States,
      • Backstrand J.R.
      The history and future of food fortification in the United States: A public health perspective.
      US Department of Agriculture and US Department of Health and Human Services
      Dietary Guidelines for Americans, 2010.
      data are lacking on the specific contributions made by fortification of foods with micronutrients
      Committee on the Use of Dietary Reference Intakes in Nutrition Labeling, Food and Nutrition Board, Institute of Medicine
      Dietary Reference Intakes: Guiding Principles for Nutrition Labeling and Fortification.
      other than folic acid.
      • Yeung L.F.
      • Cogswell M.E.
      • Carriquiry A.L.
      • Bailey L.B.
      • Pfeiffer C.M.
      • Berry R.J.
      Contributions of enriched cereal-grain products, ready-to-eat cereals, and supplements to folic acid and vitamin B-12 usual intake and folate and vitamin B-12 status in US children: National Health and Nutrition Examination Survey (NHANES), 2003-2006.
      • Hennessy-Priest K.
      • Mustard J.
      • Keller H.
      • et al.
      Folic acid food fortification prevents inadequate folate intake among preschoolers from Ontario.
      To ascertain the effects of fortification on children's dietary quality, it is essential to examine the specific sources of nutrients as well as the overall levels of nutrient intake. Subar and colleagues determined which food sources contributed the highest amounts of nutrients to diets of US children in 1989-1991.
      • Subar A.F.
      • Krebs-Smith S.M.
      • Cook A.
      • Kahle L.L.
      Dietary sources of nutrients among US children, 1989 to 1991.
      Although they concluded that fortified foods, especially ready-to-eat (RTE) cereals, made large contributions to intakes of many nutrients,
      • Subar A.F.
      • Krebs-Smith S.M.
      • Cook A.
      • Kahle L.L.
      Dietary sources of nutrients among US children, 1989 to 1991.
      the amounts contributed by added nutrients contained in fortified foods were not specifically examined. There has been a lack of information about the impact of fortification on nutrient adequacy and excess among children in the United States, and what foods are making the largest contributions to intakes of added nutrients.
      Recently, Fulgoni and colleagues
      • Fulgoni V.L.
      • Keast D.R.
      • Bailey R.L.
      • Dwyer J.
      Foods, fortificants, and supplements: Where do Americans get their nutrients?.
      quantified nutrient intakes contributed from naturally occurring and added nutrients contained in foods consumed by Americans 2 years of age and older, using data from the National Health and Nutrition Examination Survey (NHANES) 2003-2006. Fortification contributed greatly to intakes of many micronutrients, reducing the percentage of the population having intakes below the Estimated Average Requirement (EAR) without adding appreciably to the percentage having intakes above the Upper Tolerable Intake Level (UL).
      • Fulgoni V.L.
      • Keast D.R.
      • Bailey R.L.
      • Dwyer J.
      Foods, fortificants, and supplements: Where do Americans get their nutrients?.
      Fulgoni and colleagues' analysis reported data only for children aged 2 to 18 years as a group,
      • Fulgoni V.L.
      • Keast D.R.
      • Bailey R.L.
      • Dwyer J.
      Foods, fortificants, and supplements: Where do Americans get their nutrients?.
      yet food-consumption patterns might differ greatly by age and sex. Therefore, one goal of this report was to quantify the impact of fortification by age and sex subgroups of children.
      Another goal of this report was to determine the food sources of added nutrient intake, to rank them, and to compare these rankings of added nutrient sources with rankings based on total (both intrinsic and added) nutrient intake from foods consumed by children and adolescents.

      Methods

      Study Population

      The 2003-2004 and 2005-2006 What We Eat in America dietary intake components and dietary supplement data from NHANES, a continuous nationally representative population-based survey, were combined for this study. Details of NHANES study design, implementation, datasets, analytic considerations, and other documentation are available online.

      National Center for Health Statistics, Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey questionnaires, datasets, and related documentation, NHANES 2003-2004. http://www.cdc.gov/nchs/nhanes/nhanes2003-2004/nhanes03_04.htm. Accessed July 25, 2010.

      National Center for Health Statistics, Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey questionnaires, datasets, and related documentation, NHANES 2005-2006. http://www.cdc.gov/nchs/nhanes/nhanes2005-2006/nhanes05_06.htm. Accessed July 25, 2010.

      The analytic sample included participants aged 2 to 18 years having complete, reliable 24-hour dietary recall data, and excluded pregnant and/or lactating females. As described in online documentation,

      National Center for Health Statistics, Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey questionnaires, datasets, and related documentation, NHANES 2003-2004. http://www.cdc.gov/nchs/nhanes/nhanes2003-2004/nhanes03_04.htm. Accessed July 25, 2010.

      National Center for Health Statistics, Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey questionnaires, datasets, and related documentation, NHANES 2005-2006. http://www.cdc.gov/nchs/nhanes/nhanes2005-2006/nhanes05_06.htm. Accessed July 25, 2010.

      in-person health examinations, which included a 24-hour dietary recall, were completed at the Mobile Examination Center, and a second 24-hour recall was collected via telephone 3 to 10 days later. Parents/guardians of children aged 2 to 5 years provided the dietary recalls and children aged 6 to 11 years were assisted by an adult. All participants or proxies provided written informed consent and the Research Ethics Review Board at the National Center for Health Statistics approved the survey protocol.

      National Center for Health Statistics, Centers for Disease Control and Prevention. NCHS Research Ethics Review Board (ERB) Approval. http://www.cdc.gov/nchs/nhanes/irba98.htm. Accessed March 23, 2012.

      Nutrient Sources in Foods and Nutrient Intakes

      The sources of nutrients added by enrichment or fortification were separated from naturally occurring (intrinsic) nutrients in foods eaten by NHANES participants. Enrichment was defined as the addition of thiamin, niacin, riboflavin, folic acid, and iron to refined grain foods/ingredients as determined by US Food and Drug Administration standards of identity for enriched cereal grain products, and fortification included nutrient additions to all other foods (such as breakfast cereals, granola bars, juice drinks, and milk). The underlying databases and strategies used to develop the nutrient sources food composition data are described in detail elsewhere.
      • Fulgoni V.L.
      • Keast D.R.
      • Bailey R.L.
      • Dwyer J.
      Foods, fortificants, and supplements: Where do Americans get their nutrients?.
      Briefly, this was a data-based approach that used databases, such as the US Department of Agriculture (USDA) Food and Nutrient Database for Dietary Studies, versions 2.0 and 3.0

      US Department of Agriculture. USDA Food and Nutrient Database for Dietary Studies, 2.0. Beltsville, MD: Agricultural Research Service, Food Surveys Research Group; 2006. http://www.ars.usda.gov/services/docs.htm?docid=12089. Accessed January 3, 2014.

      US Department of Agriculture. USDA Food and Nutrient Database for Dietary Studies, 3.0. Beltsville, MD: Agricultural Research Service, Food Surveys Research Group; 2008. http://www.ars.usda.gov/services/docs.htm?docid=12089. Accessed January 3, 2014.

      ; the USDA Standard Reference datasets, versions 18 and 20

      US Department of Agriculture, Agricultural Research Service. 2005. USDA National Nutrient Database for Standard Reference, Release 18. Nutrient Data Laboratory Home Page, http://www.ars.usda.gov/ba/bhnrc/ndl. Accessed December 4, 2013.

      US Department of Agriculture, Agricultural Research Service. 2007. USDA National Nutrient Database for Standard Reference, Release 20. Nutrient Data Laboratory Home Page, http://www.ars.usda.gov/ba/bhnrc/ndl. Accessed December 4, 2013.

      ; and the USDA MyPyramid Equivalent Database, version 2.0.

      US Department of Agriculture. MyPyramid Equivalent Database version 2.0. for USDA Survey Foods, 2003-2004: Documentation and User Guide. http://www.ars.usda.gov/SP2UserFiles/Place/12355000/pdf/mped/mped2_doc.pdf. December 4, 2013.

      Added nutrients in foods were identified using different strategies, depending on the nutrient and food. For example, added folic acid, vitamin E, and vitamin B-12 data are readily available in the Standard Reference. Besides folic acid, amounts of other nutrients added during grain enrichment (thiamin, riboflavin, niacin, and iron) were determined by calculating the difference between nutrient content of enriched and unenriched versions of grain foods/ingredients in the Standard Reference. A similar approach was taken for foods such as juices, where nutrient composition data were available for comparable fortified and unfortified versions of the food. As another example, amounts of intrinsic nutrients contained in manufactured fortified foods, such as RTE cereals, were first calculated by applying representative nutrient data to food compositional data available from the MyPyramid Equivalent Database, and then added nutrients were calculated as the difference between total nutrient content and estimated intrinsic nutrient content of the food. Additional details of the approaches used have been published previously.
      • Fulgoni V.L.
      • Keast D.R.
      • Bailey R.L.
      • Dwyer J.
      Foods, fortificants, and supplements: Where do Americans get their nutrients?.
      Also, as described previously,
      • Fulgoni V.L.
      • Keast D.R.
      • Bailey R.L.
      • Dwyer J.
      Foods, fortificants, and supplements: Where do Americans get their nutrients?.
      nutrient intakes from food sources and dietary supplements were determined using 2 days of 24-hour dietary recall data, along with dietary supplement questionnaire data. Components of the dataset included the intake per day of total nutrients (from both food and dietary supplements), nutrients from food (both intrinsic and added), and nutrients added to food. Sample-weighted mean intake of each nutrient and percentages of total nutrient intake contributed from each source were determined using day 1 recall data because the mean is an unbiased estimate of the group's usual mean nutrient intake.
      • Guenther P.M.
      • Kott P.S.
      • Carriquiry A.L.
      Development of an approach for estimating usual nutrient intake distributions at the population level.
      The appropriate way to estimate nutrient intake inadequacy in a population is to determine the percentage of the group with usual intake below the Estimated Average Requirement (%<EAR), and possible excessive intakes are best estimated as the percentage of the group with usual intake above the Upper Tolerable Level (%>UL).
      The National Cancer Institute method,
      • Tooze J.A.
      • Kipnis V.
      • Buckman D.W.
      • et al.
      A mixed-effects model approach for estimating the distribution of usual intake of nutrients: The NCI method.

      National Cancer Institute. Usual Dietary Intakes: SAS Macros for Analysis of a Single Dietary Component. http://riskfactor.cancer.gov/diet/usualintakes/macros_single.html. Accessed July 25, 2010.

      applied to the 2 days of dietary intake data, was used to determine usual nutrient intakes as described elsewhere.
      • Fulgoni V.L.
      • Keast D.R.
      • Bailey R.L.
      • Dwyer J.
      Foods, fortificants, and supplements: Where do Americans get their nutrients?.
      The %<EAR was determined for all micronutrients except vitamin K and potassium, which have only Adequate Intake values, and %>UL was determined if the UL had been established. Usual intake of retinol and added vitamin E, niacin, folic acid, and magnesium were determined to assess %>UL because the UL for only those nutrient forms were established.
      The impact of fortification on usual intakes less than EAR or above the UL was determined by comparing results of analyses of intrinsic vs total food nutrients (intrinsic and added). The additional impact on intakes due to dietary supplements was determined by comparing results of analyses of food vs total nutrients (food and supplements).

      Ranked Food Sources of Total and Added Nutrients

      To determine food sources of total and added nutrients, it was first necessary to define food groupings of interest. The schemes described by Cook and colleagues

      Cook AJ, Friday JE, Subar AF. Database for Analyzing Dietary Sources of Nutrients Using USDA Survey Food Codes, August 2004 (version 1). http://www.ars.usda.gov/Services/docs.htm?docid=8498. Accessed March 23, 2012.

      and Cotton and colleagues
      • Cotton P.A.
      • Subar A.F.
      • Friday J.E.
      • Cook A.
      Dietary sources of nutrients among US adults, 1989 to 1991.
      (who identified 113 dietary source groups within nine major food categories) were used as the basis for food classification, although some food groupings were modified or collapsed to form the 56 groups shown in Figure 1. Mixtures of foods were not disaggregated because the interest in this research was to examine food sources of nutrients on an “as reported” basis. Rather, each food in the What We Eat in America/NHANES was assigned to a food grouping based on its main ingredient. Many groups included discrete foods, such as apples, milk, etc. However, if the food group included mixtures, nutrients attributed to that group could be contributed from various components of the food mixture. For example, “pasta dishes” would include foods such as lasagna, in which the main ingredient is pasta; the tomato sauce, cheese, meat, and other ingredients would also contribute to nutrient intakes from the pasta dishes group. Similarly, “white potatoes” can include nutrient contributions from milk or another ingredient in a potato dish, such as mashed potatoes, and “mixtures mainly meat” would include contributions from ingredients such as carrots in beef stew.
      Figure 1Food groupings used when determining food sources of nutrients.
      Grain Products; Mixtures Mostly Grain

       Flour, bran, baking ingredients

       Yeast bread and rolls

       Hot breakfast cereal

       Ready-to-eat cereal

       Granola/cereal bars and toaster pastries

       Rice, cooked grains

       Pasta

       Biscuits, corn bread, pancakes, tortillas

       Crackers, popcorn, pretzels, chips

       Pizza, turnovers

       Sandwiches (eg, hamburgers), bread mixtures

       Rice mixtures

       Pasta dishes (eg, macaroni and cheese)

       Tortilla and taco mixtures

      Vegetables

       Potatoes (white)

       Broccoli, spinach, greens

       Carrots, sweet potatoes, winter squash

       Tomatoes, tomato/vegetable juice

       Lettuce

       String beans (green, yellow, wax)

       Corn, peas, lima beans

       Olives, pickles

       Other vegetables

       Mixed vegetables, vegetable mixtures

      Fruit

       Fruit

       Fruit juice

      Dairy Products

       Milk

       Milk drinks

       Yogurt

       Cheese
      Meat, Poultry, Fish

      Beef

      Lamb, veal, game

      Pork, ham, bacon

      Organ meats

      Frankfurters, sausages, luncheon meats

      Poultry

      Fish and shellfish

      Mixtures mainly meat, poultry, fish (eg,

      beef stew)

      Eggs, Legumes, Nuts, and Seeds

      Eggs

      Legumes

      Nuts, seeds (includes butters, pastes)

      Fats and Oils

      Margarine and butter

      Salad dressings, mayonnaise

      Other fats and oils

      Desserts and Sweets

      Cake, cookies, quick bread, pastry, pie

      Milk desserts

      Candy, sugars, and sugary foods

      Beverages

      Fruit drinks and -ades

      Soft drinks, soda (includes diet)

      Coffee and tea

      Other nonalcoholic beverages (eg, energy drinks, sport drinks, water)

      Alcoholic beverages

      Other Foods

      Meal replacements/supplements

      Soup, broth, bouillon

      Condiments and sauces

      Whey and artificial sweeteners
      Using day 1 food intake data, mean intakes of total and added nutrients contributed from each group of foods were determined. The percentage of intake contributed from each food group was determined as a ratio by dividing the nutrient intake contributed from the specific food group by the nutrient intake from all foods. Percentages of total and added nutrients contributed by food groups were calculated separately, and ranked in descending order. Analyses incorporated NHANES sample weights, so intake estimates are representative of the US population.

      Statistical Analyses

      Analyses were stratified by age and sex subgroups, including children aged 2 to 8 years (n=2,601; sexes combined), children/adolescents aged 9 to 18 years (n=4,649), males aged 9 to 13 years (n=1,009), females aged 9 to 13 years (n=1,039), males aged 14 to 18 years (n=1,351), and females aged 14 to 18 years (n=1,250). Sample weights were applied in all analyses to adjust for oversampling and survey response.

      National Center for Health Statistics, Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey questionnaires, datasets, and related documentation, NHANES 2003-2004. http://www.cdc.gov/nchs/nhanes/nhanes2003-2004/nhanes03_04.htm. Accessed July 25, 2010.

      National Center for Health Statistics, Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey questionnaires, datasets, and related documentation, NHANES 2005-2006. http://www.cdc.gov/nchs/nhanes/nhanes2005-2006/nhanes05_06.htm. Accessed July 25, 2010.

      SAS software, version 9.2 (2003, SAS Institute) was used for usual intake analyses to determine percentages of the population having intakes less than the EAR and greater than the UL. SUDAAN software version 9.0.3 (2007, RTI) was used to adjust the variance for the complex sample design when determining mean (±standard error) micronutrient intake and the percentage of intake supplied by fortification, as well as food sources of nutrient intakes.

      Results

      Figure 2 shows the prevalence of inadequate intakes (%<EAR) in the age/sex subgroup (children aged 2 to 8 years) having the lowest levels of inadequacy and in the subgroup (females aged 14 to 18 years) having the highest levels of inadequacy. Table 1 summarizes the estimates of inadequate (%<EAR) or potentially excessive (%>UL) micronutrient intakes for each age/sex subgroup of children, by source of the nutrients. Among all age/sex subgroups, when considering only intrinsic nutrient intake from foods, approximately 25% to 100% had inadequate intakes of numerous nutrients, including vitamins A, D, E, folate, and calcium. Among females aged 14 to 18 years, approximately 23% to 92% also had inadequate intakes of thiamin, riboflavin, niacin, vitamin B-6, vitamin C, phosphorus, magnesium, iron, and zinc; and a large percentage of other subgroups of children aged 9 years and older had inadequate intakes of some of these nutrients as well. When nutrient intakes contributed from fortification were added, the %<EAR for vitamins A, D, B-6, C, the five enrichment nutrients, and zinc shifted sharply lower. However, there was less change in %<EAR for vitamin E, calcium, or other minerals (Figure 2; Table 1). Except for vitamins D and E, there was relatively little additional impact of dietary supplements on %<EAR for most nutrients.
      Figure thumbnail gr2
      Figure 2Percentage of the population with usual intake below the Estimated Average Requirement. Subgroups shown had the lowest (A, children aged 2 to 8 years) and highest (B, females aged 14 to 18 years) prevalence of inadequate intakes among the total population aged 2 to 18 years.
      Data from National Health and Nutrition Examination Survey 2003-2006.
      Table 1Percentage of children having usual micronutrient intakes below the Estimated Average Requirement and above the Upper Tolerable Level, considering only the food's intrinsic nutrients, both intrinsic and added nutrients from food, and nutrients from food plus supplements
      Data from National Health and Nutrition Examination Survey 2003-2006; usual intake determined using the National Cancer Institute method, with covariates including the recall number, weekday/weekend day, and dietary supplement use (yes/no).
      Upper Tolerable Level for vitamin A based only on retinol. Upper Tolerable Level for vitamin E, niacin, folate, and Mg based only on added nutrients (fortification/enrichment and supplements).
      Nutrient and sourceChildren 2 to 8 Years Old (n=2,601)Males 9 to 13 Years Old (n=1,009)Females 9 to 13 Years Old (n=1,039)Males 14 to 18 Years Old (n=1,351)Females 14 to 18 Years Old (n=1,250)
      % <EAR
      EAR=Estimated Average Requirement.
      % ≥UL
      UL=Upper Tolerable Level.
      % <EAR% ≥UL% <EAR% ≥UL% <EAR% ≥UL% <EAR% ≥UL
      Vitamin A
      Intrinsic only24.6060.3074.6087.5089.20
      Intrinsic+added nutrients5.713.424.5<130.8056.4057.20
      Food+supplements4.7ND
      ND=not determined. Data are available separated by users vs nonusers of supplements in Bailey and colleagues.23
      20.9ND26.4ND50.7ND50.7ND
      Vitamin D
      Intrinsic only10001000100010001000
      Intrinsic+added nutrients80.6086.1092.0088.2097.60
      Food+supplements62.60.275.80.477.90.480.6086.90
      Vitamin E
      Intrinsic only69.9NA
      NA=not applicable because Upper Tolerable Level does not apply to the intrinsic form of the nutrient.
      87.1NA94.7NA96.2NA99.5NA
      Intrinsic+added nutrients65.0085.5090.7094.6098.70
      Food+supplements46.70.271.9072.5083.7084.00.2
      Thiamin
      Intrinsic only8.9
      Dashes indicate no Upper Tolerable Level has been established.
      27.643.355.685.6
      Intrinsic+added nutrients0.10.21.41.510.2
      Food+supplements0.10.21.21.29.0
      Riboflavin
      Intrinsic only0.33.57.59.422.7
      Intrinsic+added nutrients00.31.01.24.7
      Food+supplements00.30.81.04.2
      Niacin
      Intrinsic only2.9NA4.9NA15.6NA7.3NA35.0NA
      Intrinsic+added nutrients0.18.20.12.70.80.40.20.24.10
      Food+supplements0.128.40.112.00.810.90.24.43.82.5
      Folate
      Intrinsic only56.1NA90.6NA94.5NA96.3NA99.7NA
      Intrinsic+added nutrients0.29.71.31.13.40.44.00.119.00
      Food+supplements0.130.30.97.63.06.83.62.416.41.2
      Vitamin B-6
      Intrinsic only0.905.2012.0010.1038.60
      Intrinsic+added nutrients0.101.104.002.9017.80
      Food+supplements0.10.21.003.402.70.415.30.1
      Vitamin B-12
      Intrinsic only0.10.32.00.713.7
      Intrinsic+added nutrients00.10.70.36.5
      Food+supplements00.10.70.25.6
      Vitamin C
      Intrinsic only5.1030.3029.1052.6060.50
      Intrinsic+added nutrients2.0019.6017.6038.7044.80
      Food+supplements1.51.016.50.414.60.133.8037.70.2
      Calcium
      Intrinsic only27.80.162.8076.1053.1085.60
      Intrinsic+added nutrients22.50.357.6070.6047.40.181.40
      Food+supplements21.20.455.40.168.1045.20.277.30.2
      Phosphorus
      Intrinsic only0.2020.4038.3010.6050.30
      Intrinsic+added nutrients0.2019.6037.209.9048.10
      Food+supplements0.1019.2035.909.8047.10
      Magnesium
      Intrinsic only1.9NA26.0NA42.9NA79.3NA91.7NA
      Intrinsic+added nutrients1.90.224.9040.9075.6089.70
      Food+supplements1.80.423.8038.6073.20.286.00.1
      Iron
      Intrinsic only11.206.6015.8013.8051.80
      Intrinsic+added nutrients0.7000.10.800.50.111.50
      Food+supplements0.61.201.60.60.50.50.910.11.5
      Zinc
      Intrinsic only0.524.36.70.219.807.3036.70
      Intrinsic+added nutrients0.244.93.51.611.80.24.50.123.50
      Food+supplements0.252.73.27.510.66.44.11.920.90.9
      Copper
      Intrinsic only0.16.50.502.501.8015.60
      Intrinsic+added nutrients07.30.602.401.9015.60
      Food+supplements013.60.60.12.301.7014.00
      Selenium
      Intrinsic only07.0000.30002.40
      Intrinsic+added nutrients07.3000.300.102.10
      Food+supplements07.5000.20002.30
      a Data from National Health and Nutrition Examination Survey 2003-2006; usual intake determined using the National Cancer Institute method, with covariates including the recall number, weekday/weekend day, and dietary supplement use (yes/no).
      b Upper Tolerable Level for vitamin A based only on retinol. Upper Tolerable Level for vitamin E, niacin, folate, and Mg based only on added nutrients (fortification/enrichment and supplements).
      c EAR=Estimated Average Requirement.
      d UL=Upper Tolerable Level.
      e ND=not determined. Data are available separated by users vs nonusers of supplements in Bailey and colleagues.
      • Bailey R.L.
      • Fulgoni V.L.
      • Keast D.R.
      • Lentino C.V.
      • Dwyer J.T.
      Do dietary supplements improve micronutrient sufficiency in children and adolescents?.
      f NA=not applicable because Upper Tolerable Level does not apply to the intrinsic form of the nutrient.
      g Dashes indicate no Upper Tolerable Level has been established.
      Among most subgroups, the percentages having usual intakes above the UL were very low or zero for most nutrients, even when considering total intakes from food plus supplements (Table 1). There were a few exceptions, but only among children aged 2 to 8 years. Twenty-four percent of them had zinc intakes above the UL, even considering only the zinc intrinsic to food, with the %>UL shifted even higher by fortification and dietary supplements. The percentages above the UL for niacin and folic acid were 8.2% and 9.7%, respectively, when fortification was considered, and much higher (28.4% and 30.3%) when intakes from dietary supplements were included.
      Mean daily intake of added nutrients and percentage of the intake of nutrients from food contributed by added nutrients (both fortification and enrichment) are shown in Table 2 (available online at www.andjrnl.org). Nutrient enrichment and fortification contributed half or more of the intakes of vitamin D, thiamin, and folate; 19.9% to 47.1% of the intakes of vitamin A, vitamin C, riboflavin, niacin, B-6, B-12, and iron; 12.1% to 18.4% of the intake of zinc; 4.5% to 6.6% of calcium intake; and only negligible percentages of the other micronutrients.
      Tables 3 through 7 show ranked food sources of vitamins A, C, D, folate, and iron, nutrients that were identified in the 2010 Dietary Guideline for Americans reports

      Dietary Guidelines Advisory Committee. Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2010, to the Secretary of Agriculture and the Secretary of Health and Human Services. Washington, DC: US Department of Agriculture, Agricultural Research Service. http://www.cnpp.usda.gov/DGAs2010-DGACReport.htm. Accessed March 16, 2012.

      US Department of Agriculture and US Department of Health and Human Services
      Dietary Guidelines for Americans, 2010.
      as nutrients of concern among one or more subgroups of children and/or adolescents and for which enrichment and/or fortification contributed at least 10% of the nutrient intake from all foods. (Tables 8 through 13 [available online at www.andjrnl.org] show rankings for all other micronutrients for which enrichment and/or fortification contributed at least 10% of the intake of that nutrient from foods.) Within each table, food sources were listed if they contributed at least 2% of the nutrient intake from all foods; footnotes to the tables list food groupings each contributing at least 1% but <2% of intake. Each of the tables shows ranked food sources of total nutrients (both intrinsic and added) separately from the ranked food sources of added nutrients. The Tables also show rankings for children aged 2 to 8 years and older children/adolescents separately. (Data not shown suggested only small shifts in rankings when comparing age and sex subgroups within the entire group aged 9 to 18 years.) For both the 2- to 8-year-old and 9- to 18-year-old age groups, the major food sources of added nutrients were always among the major food sources of total nutrients, demonstrating that fortification of foods had a powerful influence on how food sources of these nutrients were ranked in American children's consumption patterns. RTE cereal (for all nutrients, Tables 3 through 7 and Tables 8 through 13 [available online at www.andjrnl.org]), milk and milk drinks (for vitamins A and D; Tables 3 and 4), juice and juice drinks (for vitamin C; Table 5), and yeast breads/rolls and other food groups containing enriched-grain ingredients (for thiamin, niacin, riboflavin, folate, and iron, Tables 6 and 7 and Tables 8 through 10 [available online at www.andjrnl.org]) predominated as food sources of both total and added nutrients.
      Table 3Top food sources of vitamin A (both intrinsic and added to foods) and top food sources of only added vitamin A in the diets of children, from National Health and Nutrition Examination Survey 2003-2006
      From day 1 dietary recall; sample weights applied.
      Table includes data for food groupings contributing ≥2% of intake for the nutrient.
      Food Sources of Both Intrinsic and Added Vitamin AFood Sources of Only Added Vitamin A
      Rank and food grouping%Cumulative %Rank and food grouping%Cumulative %
      children 2 to 8 years old
      Three additional food groupings contributed at least 1% each to total dietary intake (in descending order: fruit; soup, broth, bouillon; granola/cereal bars, toaster pastries). One additional food grouping contributed at least 1% to added nutrient intake (eggs).
      (n=2,601)
      1Milk22.622.61 Ready-to-eat cereal42.642.6
      2Ready-to-eat cereal17.039.62 Milk25.167.7
      3Milk drinks8.247.83 Milk drinks11.779.4
      4Carrots, sweet potato, winter squash4.952.74 Pasta dishes3.582.9
      5Cheese4.657.35 Margarine, butter3.186.0
      6Milk desserts4.161.46 Bars/toaster pastries2.888.8
      7Pasta dishes3.765.17 Cake, cookie, quick bread, pastry, pie2.391.1
      8Mixtures mainly meat3.668.78 Fruit drinks/-ades2.093.1
      9Eggs3.372.0
      10 Biscuits, cornbread, pancakes, tortillas3.075.0
      11 Pizza, turnovers2.777.7
      12 Margarine, butter2.380.0
      13 Hot breakfast cereal2.382.3
      14 Cake, cookie, quick bread, pastry, pie2.084.3
      children/adolescents 9 to 18 years old
      Seven additional food groupings contributed at least 1% each to total dietary intake (in descending order: sandwiches, bread mixtures; tortilla, taco mixtures; other fats and oils; fruit; broccoli, spinach, greens; soup, broth, bouillon; fruit juice). Three additional food groupings contributed at least 1% each to added nutrient intake (in descending order: eggs; meal replacements/supplements; white potatoes).
      (n=4,649)
      1Milk19.619.61 Ready-to-eat cereal37.637.6
      2Ready-to-eat cereal13.733.32 Milk29.166.7
      3Cheese6.039.33 Bars/toaster pastries7.374.0
      4Carrots, sweet potato, winter squash5.845.14 Milk drinks5.879.8
      5Milk desserts4.749.85 Cake, cookie, quick bread, pastry, pie3.783.5
      6Pizza, turnovers4.654.46 Margarine, butter3.386.8
      7Milk drinks4.458.87 Pasta dishes2.889.6
      8Mixtures mainly meat3.662.4
      9Pasta dishes3.265.6
      10 Eggs3.268.8
      11 Cake, cookie, quick bread, pastry, pie3.071.8
      12 Biscuits, cornbread, pancakes, tortillas2.974.7
      13 Bars/toaster pastries2.777.4
      14 Margarine, butter2.379.7
      a From day 1 dietary recall; sample weights applied.
      b Table includes data for food groupings contributing ≥2% of intake for the nutrient.
      c Three additional food groupings contributed at least 1% each to total dietary intake (in descending order: fruit; soup, broth, bouillon; granola/cereal bars, toaster pastries). One additional food grouping contributed at least 1% to added nutrient intake (eggs).
      d Seven additional food groupings contributed at least 1% each to total dietary intake (in descending order: sandwiches, bread mixtures; tortilla, taco mixtures; other fats and oils; fruit; broccoli, spinach, greens; soup, broth, bouillon; fruit juice). Three additional food groupings contributed at least 1% each to added nutrient intake (in descending order: eggs; meal replacements/supplements; white potatoes).
      Table 4Top food sources of vitamin D (both intrinsic and added to foods) and top food sources of only added vitamin D in the diets of children, from National Health and Nutrition Examination Survey 2003-2006
      From day 1 dietary recall; sample weights applied.
      Table includes data for food groupings contributing ≥2% of intake for the nutrient.
      Food Sources of Both Intrinsic and Added Vitamin DFood Sources of Only Added Vitamin D
      Rank and food grouping%Cumulative %Rank and food grouping%Cumulative %
      children 2 to 8 years old
      Five additional food groupings contributed at least 1% each to total dietary intake (in descending order: mixtures mainly meat/fish poultry; pasta dishes; frankfurters, sausages, luncheon meats; yogurt; fish/shellfish). Two additional food groupings contributed at least 1% each to added nutrient intake (in descending order: yogurt; pasta dishes).
      (n=2,601)
      1 Milk56.156.11 Milk66.766.7
      2 Milk drinks15.071.12 Milk drinks16.583.2
      3 Ready-to-eat cereal8.379.43 Ready-to-eat cereal10.593.7
      4 Eggs2.782.1
      5 Fruit juice2.684.7
      children/adolescents 9 to 18 years old
      Five additional food groupings contributed at least 1% each to total dietary intake (in descending order: pasta dishes; pork/ham/bacon; cheese; pizza, turnovers; sandwiches, bread mixtures). Two additional food groupings contributed at least 1% each to added nutrient intake (in descending order: pasta dishes; yogurt).
      (n=4,649)
      1 Milk51.851.81 Milk67.667.6
      2 Milk drinks9.861.62 Milk drinks12.279.8
      3 Ready-to-eat cereal8.069.63 Ready-to-eat cereal11.691.4
      4 Fruit juice3.372.9
      5 Eggs3.176.0
      6 Mixtures mainly meat3.179.1
      7 Fish, shellfish2.781.8
      8 Frankfurters, sausages, lunch meats2.183.9
      a From day 1 dietary recall; sample weights applied.
      b Table includes data for food groupings contributing ≥2% of intake for the nutrient.
      c Five additional food groupings contributed at least 1% each to total dietary intake (in descending order: mixtures mainly meat/fish poultry; pasta dishes; frankfurters, sausages, luncheon meats; yogurt; fish/shellfish). Two additional food groupings contributed at least 1% each to added nutrient intake (in descending order: yogurt; pasta dishes).
      d Five additional food groupings contributed at least 1% each to total dietary intake (in descending order: pasta dishes; pork/ham/bacon; cheese; pizza, turnovers; sandwiches, bread mixtures). Two additional food groupings contributed at least 1% each to added nutrient intake (in descending order: pasta dishes; yogurt).
      Table 5Top food sources of vitamin C (both intrinsic and added to foods) and top food sources of only added vitamin C in the diets of children, from National Health and Nutrition Examination Survey 2003-2006
      From day 1 dietary recall; sample weights applied.
      Table includes data for food groupings contributing ≥2% of intake for the nutrient.
      Food Sources of Both Intrinsic and Added Vitamin CFood Sources of Only Added Vitamin C
      Rank and food grouping%Cumulative %Rank and food grouping%Cumulative %
      children 2 to 8 years old
      Four additional food groupings contributed at least 1% each to total dietary intake (in descending order: other vegetables; milk drinks; pasta dishes; mixtures mainly meat, poultry, fish).
      (n=2,601)
      1 Fruit juice37.937.91 Fruit drinks/-ades57.157.1
      2 Fruit drinks/-ades22.460.32 Fruit juice21.178.2
      3 Fruit12.572.83 Ready-to-eat cereal18.396.5
      4 Ready-to-eat cereal4.977.7
      5 Candy, sugars, and sugary foods3.881.5
      6 White potatoes2.383.8
      7 Broccoli, spinach, greens2.286.0
      children/adolescents 9 to 18 years old
      Five additional food groupings contributed at least 1% each to total dietary intake (in descending order: broccoli, spinach, greens; crackers, popcorn, pretzels, chips; pasta dishes; tomatoes, tomato/vegetable juice; condiments and sauces).
      (n=4,649)
      1 Fruit juice32.432.41 Fruit drinks/-ades72.172.1
      2 Fruit drinks/-ades23.756.12 Ready-to-eat cereal19.691.7
      3 Fruit11.467.53 Fruit juice3.094.7
      4 Ready-to-eat cereal3.971.44 Other nonalcoholic beverages2.397.0
      5 White potatoes3.274.6
      6 Other vegetables2.977.5
      7 Candy, sugars, and sugary foods2.680.1
      8 Mixtures mainly meat2.582.6
      9 Pizza, turnovers2.485.0
      a From day 1 dietary recall; sample weights applied.
      b Table includes data for food groupings contributing ≥2% of intake for the nutrient.
      c Four additional food groupings contributed at least 1% each to total dietary intake (in descending order: other vegetables; milk drinks; pasta dishes; mixtures mainly meat, poultry, fish).
      d Five additional food groupings contributed at least 1% each to total dietary intake (in descending order: broccoli, spinach, greens; crackers, popcorn, pretzels, chips; pasta dishes; tomatoes, tomato/vegetable juice; condiments and sauces).
      Table 6Top food sources of folate (both intrinsic and added to foods) and top food sources of only added folate in the diets of children, from National Health and Nutrition Examination Survey 2003-2006
      From day 1 dietary recall; sample weights applied.
      Table includes data for food groupings contributing ≥2% of intake for the nutrient.
      Food Sources of Both Intrinsic and Added FolateFood Sources of Only Added Folate
      Rank and food grouping%Cumulative %Rank and food grouping%Cumulative %
      children 2 to 8 years old
      Ten additional food groupings contributed at least 1% each to added nutrient intake (in descending order: mixtures mainly meat, poultry, fish; white potatoes; soup, broth, bouillon; rice, cooked grains; sandwiches, bread mixtures; legumes; milk drinks; eggs; tortilla, taco mixtures; hot breakfast cereals). Seven additional food groupings contributed at least 1% each to added nutrient intake (in descending order: sandwiches, bread mixtures; mixtures mainly meat, poultry, fish; hot breakfast cereal; soup, broth, bouillon; pasta; tortilla, taco mixtures; rice mixtures).
      (n=2,601)
      1Ready-to-eat cereal30.530.51 Ready-to-eat cereal48.248.2
      2Yeast bread, rolls9.740.22 Yeast bread, rolls11.259.4
      3Pizza, turnovers6.046.23 Pasta dishes7.767.1
      4Pasta dishes6.052.24 Pizza, turnovers6.573.6
      5Crackers, popcorn, pretzels, chips4.556.75 Cake, cookie, quick bread, pastry, pie4.678.2
      6Milk4.160.86 Biscuits, cornbread, pancakes, tortillas3.882.0
      7Cake, cookie, quick bread, pastry, pie3.864.67 Crackers, popcorn, pretzels, chips3.885.8
      8Fruit juice3.767.88 Rice, cooked grains2.488.2
      9Biscuits, cornbread, pancakes, tortillas3.271.0
      10 Fruit2.373.3
      children/adolescents 9 to 18 years old
      Eight additional food groupings contributed at least 1% each to total dietary intake (in descending order: white potatoes; legumes; fruit; nuts, seeds, including butters/pastes; rice, cooked grains; granola/cereal bars, toaster pastries; rice mixtures; soup, broth, bouillon). Four additional food groupings contributed at least 1% each to added nutrient intake (in descending order: mixtures mainly meat, poultry, fish; granola/cereal bars, toaster pastries; rice mixtures; soup, broth, bouillon).
      (n=4,649)
      1Ready-to-eat cereal22.022.01Ready-to-eat cereal36.136.1
      2Yeast bread, rolls13.335.32  Yeast bread, rolls16.352.4
      3Pizza, turnovers9.745.03Pizza, turnovers10.963.3
      4Pasta dishes5.050.04Pasta dishes6.669.9
      5Crackers, popcorn, pretzels, chips4.454.45Cake, cookie, quick bread, pastry, pie5.175.0
      6Cake, cookie, quick bread, pastry, pie4.058.46Biscuits, cornbread, pancakes, tortillas4.479.4
      7Sandwiches, bread mixtures3.561.97Sandwiches, bread mixtures3.783.1
      8Biscuits, cornbread, pancakes, tortillas3.465.38Crackers, popcorn, pretzels, chips3.786.8
      9Fruit juice3.268.59Tortilla, taco mixtures2.689.4
      10 Milk2.871.310 Rice, cooked grains2.291.6
      11 Tortilla, taco mixtures2.874.1
      12 Mixtures mainly meat2.476.5
      a From day 1 dietary recall; sample weights applied.
      b Table includes data for food groupings contributing ≥2% of intake for the nutrient.
      c Ten additional food groupings contributed at least 1% each to added nutrient intake (in descending order: mixtures mainly meat, poultry, fish; white potatoes; soup, broth, bouillon; rice, cooked grains; sandwiches, bread mixtures; legumes; milk drinks; eggs; tortilla, taco mixtures; hot breakfast cereals). Seven additional food groupings contributed at least 1% each to added nutrient intake (in descending order: sandwiches, bread mixtures; mixtures mainly meat, poultry, fish; hot breakfast cereal; soup, broth, bouillon; pasta; tortilla, taco mixtures; rice mixtures).
      d Eight additional food groupings contributed at least 1% each to total dietary intake (in descending order: white potatoes; legumes; fruit; nuts, seeds, including butters/pastes; rice, cooked grains; granola/cereal bars, toaster pastries; rice mixtures; soup, broth, bouillon). Four additional food groupings contributed at least 1% each to added nutrient intake (in descending order: mixtures mainly meat, poultry, fish; granola/cereal bars, toaster pastries; rice mixtures; soup, broth, bouillon).
      Table 7Top food sources of iron (both intrinsic and added to foods) and top food sources of only added iron in the diets of children, from National Health and Nutrition Examination Survey 2003-2006
      From day 1 dietary recall; sample weights applied.
      Table includes data for food groupings contributing ≥2% of intake for the nutrient.
      Food Sources of Both Intrinsic and Added IronFood Sources of Only Added Iron
      Rank and food grouping%Cumulative %Rank and food grouping%Cumulative %
      children 2 to 8 years old
      Eleven additional food groupings contributed at least 1% each to total dietary intake (in descending order: milk drinks; sandwiches, bread mixtures; soup, broth, bouillon; white potatoes; beef; frankfurters, sausages, luncheon meats; eggs; fruit; tortilla, taco mixtures; candy, sugars, and sugary foods; legumes). Four additional food groupings contributed at least 1% each to added nutrient intake (in descending order: rice, cooked grains; granola/cereal bars, toaster pastries; sandwiches, bread mixtures; mixtures mainly meat, poultry, fish).
      (n=2,601)
      1Ready-to-eat cereal28.528.51 Ready-to-eat cereal59.059.0
      2Yeast bread, rolls8.537.02 Yeast bread, rolls9.568.5
      3Pizza, turnovers5.442.43 Pizza, turnovers6.174.6
      4Cake, cookie, quick bread, pastry, pie4.947.34 Cake, cookie, quick bread, pastry, pie4.879.4
      5Crackers, popcorn, pretzels, chips4.852.15 Pasta dishes3.382.7
      6Pasta dishes4.656.76 Biscuits, cornbread, pancakes, tortillas3.285.9
      7Fruit juice3.960.67 Crackers, popcorn, pretzels, chips3.189.0
      8Biscuits, cornbread, pancakes, tortillas3.964.5
      9Mixtures mainly meat2.967.4
      10 Poultry2.169.5
      11 Hot breakfast cereal2.071.5
      children/adolescents 9 to 18 years old
      Nine additional food groupings contributed at least 1% each to total dietary intake (in descending order: potatoes; granola/cereal bars, toaster pastries; frankfurters, sausages, luncheon meats; soup, broth, bouillon; eggs; candy, sugars, and sugary foods; legumes; rice mixtures; nuts, seeds including butters/pastes). Four additional food groupings contributed at least 1% each to added nutrient intake (in descending order: rice, cooked grains; mixtures mainly meat, poultry, fish; rice mixtures; meal replacements/supplements).
      (n=4,649)
      1Ready-to-eat cereal19.219.21Ready-to-eat cereal44.044.0
      2Yeast bread, rolls11.030.22Yeast bread, rolls14.858.8
      3Pizza, turnovers8.839.03Pizza, turnovers11.069.8
      4Cake, cookie, quick bread, pastry, pie5.044.04Cake, cookie, quick bread, pastry, pie5.275.0
      5Crackers, popcorn, pretzels, chips4.748.75Biscuits, cornbread, pancakes, tortillas3.778.7
      6Sandwiches, bread mixtures4.252.96Crackers, popcorn, pretzels, chips3.482.1
      7Mixtures mainly meat4.056.97Sandwiches, etc3.085.1
      8Biscuits, cornbread, pancakes, tortillas3.860.78Bars/toaster pastries2.887.9
      9Pasta dishes3.864.59Pasta dishes2.790.6
      10 Beef3.367.810 Tortilla, taco mixtures2.392.9
      11 Tortilla, taco mixtures3.170.9
      12 Soft drinks, soda2.573.4
      13 Fruit juice2.375.7
      14 Poultry2.177.8
      a From day 1 dietary recall; sample weights applied.
      b Table includes data for food groupings contributing ≥2% of intake for the nutrient.
      c Eleven additional food groupings contributed at least 1% each to total dietary intake (in descending order: milk drinks; sandwiches, bread mixtures; soup, broth, bouillon; white potatoes; beef; frankfurters, sausages, luncheon meats; eggs; fruit; tortilla, taco mixtures; candy, sugars, and sugary foods; legumes). Four additional food groupings contributed at least 1% each to added nutrient intake (in descending order: rice, cooked grains; granola/cereal bars, toaster pastries; sandwiches, bread mixtures; mixtures mainly meat, poultry, fish).
      d Nine additional food groupings contributed at least 1% each to total dietary intake (in descending order: potatoes; granola/cereal bars, toaster pastries; frankfurters, sausages, luncheon meats; soup, broth, bouillon; eggs; candy, sugars, and sugary foods; legumes; rice mixtures; nuts, seeds including butters/pastes). Four additional food groupings contributed at least 1% each to added nutrient intake (in descending order: rice, cooked grains; mixtures mainly meat, poultry, fish; rice mixtures; meal replacements/supplements).

      Discussion

      The authors are not aware of publications of recent nationally representative data that distinguish or rank food sources of added micronutrients in children's diets, although there are recent publications of sources of total (intrinsic plus added) nutrient intake by children (Keast and colleagues
      • Keast D.R.
      • Fulgoni V.L.
      • Nicklas T.A.
      • O'Neil C.E.
      Food sources of energy and nutrients among children in the US: NHANES 2003-2006.
      ; and data available online showing major food sources of sodium, potassium, and calcium

      National Cancer Institute Applied Research Program. Food Sources. Risk Factor Monitoring and Methods Branch website. http://riskfactor.cancer.gov/diet/foodsources/. Updated December 21, 2010. Accessed March 23, 2012.

      ).
      For these children and adolescents, fortification added noticeably to intakes of iron and each of the shortfall vitamins identified in 2010 Dietary Guidelines for Americans reports,

      Dietary Guidelines Advisory Committee. Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2010, to the Secretary of Agriculture and the Secretary of Health and Human Services. Washington, DC: US Department of Agriculture, Agricultural Research Service. http://www.cnpp.usda.gov/DGAs2010-DGACReport.htm. Accessed March 16, 2012.

      US Department of Agriculture and US Department of Health and Human Services
      Dietary Guidelines for Americans, 2010.
      except for vitamin E, and shifted the prevalence of inadequate intakes lower. If it had not been for added nutrients, thiamin, riboflavin, niacin, vitamin B-6, and zinc might also have been considered “shortfall nutrients” in older children, particularly girls. After adding intake from dietary supplements, the %<EAR for most nutrients other than vitamins D and E did not change noticeably. An explanation might be that in 2003-2006, most children consumed fortified foods but only 26% to 42% (depending on age/sex) reported supplement use; the impact of supplements on micronutrient intakes was more notable when examining supplement users separately from the total population.
      • Bailey R.L.
      • Fulgoni V.L.
      • Keast D.R.
      • Lentino C.V.
      • Dwyer J.T.
      Do dietary supplements improve micronutrient sufficiency in children and adolescents?.
      Fortification was more influential on intakes of vitamins than minerals, but even with the increased intakes from fortification, substantial percentages of most age/sex subgroups had intakes of vitamins A, C, and D that were less than the EAR. In addition, fortification had minimal impact on the %<EAR for several shortfall nutrients, including calcium, potassium, magnesium, phosphorus, and vitamin E. On average, only about 50 mg per day or 5% of the calcium intake from food came from fortification, although this represented an increase from 1989-1991 estimates.
      • Berner L.A.
      • Clydesdale F.M.
      • Douglass J.S.
      Fortification contributed greatly to vitamin and mineral intakes in the United States, 1989-91.
      As a Food and Nutrition Board committee concluded, one of the guiding principles to justify discretionary fortification is documentation of dietary inadequacy,
      Committee on the Use of Dietary Reference Intakes in Nutrition Labeling, Food and Nutrition Board, Institute of Medicine
      Dietary Reference Intakes: Guiding Principles for Nutrition Labeling and Fortification.
      a criterion that is met for several of the nutrients mentioned. This presents an opportunity for selective fortification with nutrients such as vitamin D and calcium.
      • Newmark H.L.
      • Heaney R.P.
      • Lachance P.A.
      Should calcium and vitamin D be added to the current enrichment program for cereal-grain products?.
      • Johnson-Down L.
      • L'Abbe M.R.
      • Lee N.S.
      • Gray-Donald K.
      Appropriate calcium fortification of the food supply presents a challenge.
      • Vatanparast H.
      • Calvo M.S.
      • Green T.J.
      • Whiting S.J.
      Despite mandatory fortification of staple foods, vitamin D intakes of Canadian children and adults are inadequate.
      However, it is an ongoing challenge to improve intakes of target populations without potentially exposing others to excessive amounts.
      • Johnson-Down L.
      • L'Abbe M.R.
      • Lee N.S.
      • Gray-Donald K.
      Appropriate calcium fortification of the food supply presents a challenge.
      • Yetley E.A.
      • Rader J.I.
      Modeling the level of fortification and post-fortification assessments: US experience.
      • Sacco J.E.
      • Tarasuk V.
      Health Canada's proposed discretionary fortification policy is misaligned with the nutritional needs of Canadians.
      In addition, technical challenges, including taste, mass, or stability issues, present barriers to the addition of some shortfall nutrients; therefore, fortification is not a panacea. A recent editorial in the Journal of Pediatrics suggested that an evaluation of fortification strategies, and possible development of new products or formulations, might be helpful in addressing continued low intakes of some micronutrients by children.
      • Cole C.R.
      Preventing hidden hunger in children using micronutrient supplementation.
      The data presented here do not raise concern about fortification contributing to intakes above the UL for most micronutrients, except folic acid, niacin, and zinc, which might possibly be a concern for the youngest subgroup examined, children aged 2 to 8 years. However, the intakes might not be truly of public health concern if the UL established for children are set too low. Questions about the quantification of the UL remain because of lack of evidence of any adverse effects, even though many children have usual intakes above the UL for nutrients such as zinc; because of a lack of data on specific hazard identification relevant to children; and because the extrapolation of adult UL values to children on the basis of body weight is controversial and can be fraught with error.
      • Zlotkin S.
      Understanding tolerable upper intake levels: A critical assessment of the upper intake levels for infants and children.
      • Berner L.A.
      • Levine M.J.
      Understanding tolerable upper intake levels: Overall discussion, gaps and suggestions.
      In addition, adequate biomarkers of zinc status are not available.
      More data are needed to support evidence-based recommendations for UL values for children.
      • Zlotkin S.
      Understanding tolerable upper intake levels: A critical assessment of the upper intake levels for infants and children.
      • Berner L.A.
      • Levine M.J.
      Understanding tolerable upper intake levels: Overall discussion, gaps and suggestions.
      Consumers are advised to obtain nutrients primarily from nutrient-dense forms of foods, and “dietary supplements or fortification of certain foods may be advantageous in specific situations to increase intake of a specific vitamin or mineral.”
      US Department of Agriculture and US Department of Health and Human Services
      Dietary Guidelines for Americans, 2010.
      Despite the large nutrient contributions made by fortified foods, they are not always among the foods targeted by recommendations to increase intakes, and sometimes, as in the case of refined grain foods and juice drinks, reduced intakes might even be recommended. Recently, Reedy and Krebs-Smith examined NHANES data to determine which foods contributed most to children's intakes of energy, solid fat, and added sugar, components targeted for reduction.
      • Reedy J.
      • Krebs-Smith S.M.
      Dietary sources of energy, solid fats, and added sugars among children and adolescents in the United States.
      A direct comparison with their data is not possible because of food grouping differences, but some general comparisons can be made because they also examined food sources of nutrients without disaggregating mixtures. They reported that the top five food sources of energy for the 2- to 18-year-old age group, each supplying 5.6% to 6.8% of total energy intake, were grain desserts, pizza, soda, yeast breads, and chicken.
      • Reedy J.
      • Krebs-Smith S.M.
      Dietary sources of energy, solid fats, and added sugars among children and adolescents in the United States.
      In comparison, Tables 6 and 7 and Tables 8 through 10 (available online at www.andjrnl.org) show that yeast breads/rolls and pizza were also among the top five food sources of total and added thiamin, niacin, riboflavin, folate, and iron. Reedy and Krebs-Smith found that fruit drinks, soda, grain desserts, dairy desserts, and candy were the top five sources of added sugars.
      • Reedy J.
      • Krebs-Smith S.M.
      Dietary sources of energy, solid fats, and added sugars among children and adolescents in the United States.
      Data from this article show that fruit drinks/-ades were major sources of total and added vitamin C (Table 5), and the “cake, cookies, quick bread, pastry, and pies” group was among the top five or six sources of added enrichment nutrients (Tables 6 and 7 and Tables 8 through 10 [available online at www.andjrnl.org]). There is some overlap between major food sources of micronutrients and major sources of components targeted for reduction, and care should be taken so that following dietary advice (to limit macronutrient intake from certain foods, for example) does not have an unintended effect of reducing intake of key micronutrients.
      To determine how a dietary recommendation might affect nutrient intake, the Dietary Guidelines Advisory Committee modeled the substitution of whole grains for enriched grain foods.

      Dietary Guidelines Advisory Committee. Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2010, to the Secretary of Agriculture and the Secretary of Health and Human Services. Washington, DC: US Department of Agriculture, Agricultural Research Service. http://www.cnpp.usda.gov/DGAs2010-DGACReport.htm. Accessed March 16, 2012.

      Modeling showed that by replacing all grains with whole grains, without including fortified whole-grain products such as RTE cereals, the dietary pattern would contain inadequate levels of folate and iron, and lower (but still adequate) levels of thiamin, niacin, and riboflavin.

      Dietary Guidelines Advisory Committee. Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2010, to the Secretary of Agriculture and the Secretary of Health and Human Services. Washington, DC: US Department of Agriculture, Agricultural Research Service. http://www.cnpp.usda.gov/DGAs2010-DGACReport.htm. Accessed March 16, 2012.

      These careful scenarios assumed that other recommended components of USDA patterns (such as recommended servings of fruits and vegetables) were in compliance with food guidance. From the public health standpoint, shifts in intake of fortified foods, and any resultant nutrient intake changes, should be monitored. In addition, modified enrichment/fortification strategies might help optimize alignment of food-based and nutrient-based dietary guidance.
      Major strengths of these analyses include the ability to separate out added nutrients from nutrients intrinsic to foods, and the use of nationally representative data. Determination of usual intakes using the National Cancer Institute method also strengthened this report because usual intake distributions are essential for estimating inadequacies or excesses of nutrient intake by a population. One limitation was that, because of the lack of direct information about the formulation of RTE cereals, bars, and similar fortified foods, the added nutrient content could not be directly calculated using recipes, as it was for other foods. The strategy used to indirectly calculate the added nutrient content (described in Fulgoni and colleagues
      • Fulgoni V.L.
      • Keast D.R.
      • Bailey R.L.
      • Dwyer J.
      Foods, fortificants, and supplements: Where do Americans get their nutrients?.
      ) likely added some error to intake estimates. Also, caution should be used in making direct comparisons between food-source rankings in this publication with other published work because of the dependence of rankings on food grouping definitions.
      • Cook A.J.
      • Friday J.E.
      Food mixture or ingredient sources for dietary calcium: Shifts in food group contributions using four grouping protocols.

      Conclusions

      These data indicate that fortification made a large contribution to nutrient intakes and adequacy for many, but not all, micronutrients in the diets of US children/adolescents without leading to excessive intakes for most vitamins and minerals. Fortification had a notable influence on rankings of food sources of many nutrients. Knowledge about nutrient intakes and sources is important to put dietary advice into a practical context. Continued monitoring of top food sources and nutrient contributions from fortification will be important to inform nutrition policy, particularly in this era when childhood obesity is epidemic.

      Acknowledgements

      The authors thank Victor L. Fulgoni III, PhD (Nutrition Impact LLC, Battle Creek, MI), for the important usual intake analyses, which were completed under contract with the Fortification Committee of ILSI NA.

      Supplementary Data

      Table 2Mean intake of added nutrients, and percentage of the intake of nutrients from food supplied in children's diets by added nutrients (both fortification and enrichment), with percentages of the intake of five enrichment nutrients supplied by fortification vs enrichment shown separately
      From National Health and Nutrition Examination Survey 2003-2006, day 1 dietary recall; sample weights applied.
      NutrientChildren 2 to 8 Years Old (n=2,601)Males 9 to 13 Years Old (n=1,009)Females 9 to 13 Years Old (n=1,039)Males 14 to 18 Years Old (n=1,351)Females 14 to 18 Years Old (n=1,250)
      Mean (SE
      SE=standard error.
      )
      %Mean (SE)%Mean (SE)%Mean (SE)%Mean (SE)%
      Vitamin A (μg RAE
      RAE=retinol activity equivalent.
      )
      225.1 (10.4)39.7223.1 (11.6)35.8215.1 (17.8)39.9227.0 (12.1)34.9161.5 (11.5)34.0
      Vitamin D (μg)5.08 (0.15)79.34.14 (0.23)71.93.76 (0.32)71.54.41 (0.27)66.72.67 (0.17)67.1
      Vitamin E (mg α-tocopherol)0.17 (0.05)3.60.18 (0.12)2.70.34 (0.12)5.60.18 (0.06)2.40.10 (0.03)1.7
      Vitamin K (μg)0.37 (0.10)0.80.17 (0.11)0.31.45 (1.38)2.60.13 (0.06)0.20.34 (0.13)0.5
      Vitamin C (mg)23.57 (2.01)26.516.06 (1.96)21.416.22 (1.76)20.218.98 (1.64)18.615.02 (1.57)19.9
      Thiamin (mg)0.74 (0.01)51.1

      F
      F=fortification (all nutrient addition other than enrichment as defined here).
      21.9

      E
      E=enrichment (addition of thiamin, riboflavin, niacin, folic acid, and iron to wheat flour, pasta, bread, rice, etc, as determined by standards of identity for enriched grains).
      29.1
      0.92 (0.04)52.2

      F 18.2

      E 34.0
      0.74 (0.03)49.6

      F 15.8

      E 33.8
      1.08 (0.04)50.4

      F 16.1

      E 34.3
      0.74 (0.03)51.4

      F 15.5

      E 36.0
      Riboflavin (mg)0.61 (0.02)28.7

      F 17.1

      E 11.5
      0.71 (0.03)30.6

      F 15.9

      E 14.7
      0.55 (0.02)27.5

      F 13.1

      E 14.4
      0.84 (0.03)30.2

      F 15.0

      E 15.3
      0.54 (0.03)29.9

      F 13.7

      E 16.2
      Niacin (mg)7.18 (0.21)39.6

      F 22.7

      E 16.9
      8.88 (0.49)37.0

      F 18.8

      E 18.2
      6.92 (0.33)35.6

      F 16.8

      E 18.8
      10.90 (0.31)35.9

      F 18.1

      E 17.9
      6.57 (0.28)33.3

      F 14.3

      E 19.1
      Folate (μg)216.2 (6.4)61.2

      F 30.6

      E 30.6
      262.9 (14.1)61.7

      F 26.5

      E 35.2
      205.5 (9.0)57.3

      F 22.1

      E 35.2
      283.2 (9.3)57.9

      F 21.5

      E 36.4
      201.3 (8.5)58.2

      F 21.3

      E 36.9
      Vitamin B-6 (mg)0.47 (0.03)29.60.50 (0.05)26.80.37 (0.04)24.00.58 (0.03)24.80.32 (0.03)22.0
      Vitamin B-12 (μg)1.24 (0.08)25.01.18 (0.10)21.70.89 (0.10)19.61.76 (0.19)23.70.81 (0.07)19.9
      Calcium (mg)65.0 (4.5)6.647.5 (6.9)4.553.3 (6.9)5.659.5 (6.7)4.840.4 (5.5)4.8
      Phosphorus (mg)25.3 (2.4)2.221.6 (3.9)1.616.4 (3.1)1.424.8 (4.0)1.518.2 (2.4)1.6
      Magnesium (mg)6.8 (0.7)3.36.3 (1.4)2.55.8 (1.7)2.66.2 (1.0)2.15.0 (0.7)2.4
      Potassium (mg)13.3 (2.1)0.611.1 (4.2)0.54.4 (2.0)0.27.6 (2.1)0.310.9 (2.2)0.6
      Iron (mg)6.35 (0.19)47.1

      F 29.4

      E 17.7
      7.43 (0.34)44.1

      F 23.3

      E 20.8
      5.7 (0.32)41.3

      F 20.3

      E 21.0
      8.67 (0.36)42.8

      F 21.0

      E 21.8
      5.59 (0.27)41.4

      F 19.2

      E 22.2
      Zinc (mg)1.79 (0.08)18.41.69 (0.16)13.51.23 (0.13)12.11.59 (0.16)10.31.20 (0.18)12.2
      Copper (mg)0.02 (0.00)1.70.02 (0.00)1.40.02 (0.01)1.40.02 (0.01)1.40.01 (0.00)1.2
      Selenium (μg)0.64 (0.09)0.80.43 (0.15)0.40.46 (0.11)0.50.31 (0.06)0.20.61 (0.15)0.7
      a From National Health and Nutrition Examination Survey 2003-2006, day 1 dietary recall; sample weights applied.
      b SE=standard error.
      c RAE=retinol activity equivalent.
      d F=fortification (all nutrient addition other than enrichment as defined here).
      e E=enrichment (addition of thiamin, riboflavin, niacin, folic acid, and iron to wheat flour, pasta, bread, rice, etc, as determined by standards of identity for enriched grains).
      Table 8Top food sources of thiamin (both intrinsic and added to foods) and top food sources of only added thiamin in the diets of children, from National Health and Nutrition Examination Survey 2003-2006
      From day 1 dietary recall; sample weights applied.
      Table includes data for food groupings contributing ≥2% of intake for the nutrient.
      Food Sources of Both Intrinsic and Added ThiaminFood Sources of Only Added Thiamin
      Rank and food grouping%Cumulative %Rank and food grouping%Cumulative %
      children 2 to 8 years old
      Seven additional food groupings contributed at least 1% each to total dietary intake (in descending order: fruit; sandwiches, bread mixtures; poultry; frankfurters, sausages, luncheon meats; hot breakfast cereals; tortilla, taco mixtures; granola/cereal bars, toaster pastries). Seven additional food groupings contributed at least 1% each to added nutrient intake (in descending order: sandwiches, bread mixtures; rice, cooked grains; mixtures mainly meat, poultry, fish; granola/cereal bars, toaster pastries; soup, broth, bouillon; pasta; tortilla, taco mixtures; hot breakfast cereal).
      (n=2,601)
      1Ready-to-eat cereal20.920.91 Ready-to-eat cereal39.839.8
      2Yeast bread, rolls9.530.42 Yeast bread, rolls13.853.6
      3Milk8.038.43 Pasta dishes8.962.5
      4Pizza, turnovers6.745.14 Pizza, turnovers8.871.3
      5Pasta dishes6.051.15 Cake, cookie, quick bread, pastry, pie5.276.5
      6Biscuits, cornbread, pancakes, tortillas4.055.16 Biscuits, cornbread, pancakes, tortillas4.881.3
      7Fruit juice3.858.97 Crackers, popcorn, pretzels, chips3.284.5
      8Cake, cookie, quick bread, pastry, pie3.762.6
      9Pork, ham, bacon3.766.3
      10 Crackers, popcorn, pretzels, chips3.469.7
      11 Milk drinks2.972.6
      12 White potatoes2.875.4
      13 Mixtures mainly meat2.277.6
      children/adolescents 9 to 18 years old
      Seven additional food groupings contributed at least 1% each to total dietary intake (in descending order: granola/cereal bars, toaster pastries; poultry; frankfurters, sausages, luncheon meats; soup, broth, bouillon; milk drinks; fruit; nuts, seed including butters, pastes). Four additional food groupings contributed at least 1% each to added nutrient intake (in descending order: mixtures mainly meat, poultry, fish; rice, cooked grains; soup, broth, bouillon; rice mixtures).
      (n=4,649)
      1Ready-to-eat cereal14.714.71Ready-to-eat cereal27.927.9
      2Yeast bread, rolls12.437.12Yeast bread, rolls19.046.9
      3Pizza, turnovers11.048.13Pizza, turnovers14.261.1
      4Milk5.253.34Pasta dishes7.268.3
      5Pasta dishes4.958.25Biscuits, cornbread, pancakes, tortillas5.173.4
      6Pork, ham, bacon4.863.06Cake, cookie, quick bread, pastry, pie5.178.5
      7Biscuits, cornbread, pancakes, tortillas4.167.17Sandwiches, bread mixtures4.382.8
      8Sandwiches, bread mixtures3.971.08Tortilla, taco mixtures3.286.0
      9Cake, cookie, quick bread, pastry, pie3.974.99Bars/toaster pastries2.488.4
      10 Mixtures mainly meat3.077.910 Crackers, popcorn, pretzels, chips2.290.6
      11 White potatoes3.080.9
      12 Crackers, popcorn, pretzels, chips2.983.8
      13 Fruit juice2.786.5
      14 Tortilla, taco mixtures2.689.1
      a From day 1 dietary recall; sample weights applied.
      b Table includes data for food groupings contributing ≥2% of intake for the nutrient.
      c Seven additional food groupings contributed at least 1% each to total dietary intake (in descending order: fruit; sandwiches, bread mixtures; poultry; frankfurters, sausages, luncheon meats; hot breakfast cereals; tortilla, taco mixtures; granola/cereal bars, toaster pastries). Seven additional food groupings contributed at least 1% each to added nutrient intake (in descending order: sandwiches, bread mixtures; rice, cooked grains; mixtures mainly meat, poultry, fish; granola/cereal bars, toaster pastries; soup, broth, bouillon; pasta; tortilla, taco mixtures; hot breakfast cereal).
      d Seven additional food groupings contributed at least 1% each to total dietary intake (in descending order: granola/cereal bars, toaster pastries; poultry; frankfurters, sausages, luncheon meats; soup, broth, bouillon; milk drinks; fruit; nuts, seed including butters, pastes). Four additional food groupings contributed at least 1% each to added nutrient intake (in descending order: mixtures mainly meat, poultry, fish; rice, cooked grains; soup, broth, bouillon; rice mixtures).
      Table 9Top food sources of riboflavin (both intrinsic and added to foods) and top food sources of only added riboflavin in the diets of children, from National Health and Nutrition Examination Survey 2003-2006
      From day 1 dietary recall; sample weights applied.
      Table includes data for food groupings contributing ≥2% of intake for the nutrient.
      Food Sources of Both Intrinsic and Added RiboflavinFood Sources of Only Added Riboflavin
      Rank and food grouping%Cumulative %Rank and food grouping%Cumulative %
      children 2 to 8 years old
      Seven additional food groupings contributed at least 1% each to total dietary intake (in descending order: fruit juice; fruit; yogurt; sandwiches, bread mixtures; frankfurters, sausages, luncheon meats; soup, broth, bouillon; fruit drinks, ades). Two additional food groupings contributed at least 1% each to added nutrient intake (in descending order: sandwiches, bread mixtures; mixtures mainly meat, poultry, fish).
      (n=2,601)
      1Milk25.025.01 Ready-to-eat cereal53.753.7
      2Ready-to-eat cereal15.640.62 Yeast bread, rolls9.162.8
      3Milk drinks7.347.93 Pizza, turnovers7.270.0
      4Yeast bread, rolls4.852.74 Cake, cookie, quick bread, pastry, pie5.175.1
      5Pizza, turnovers4.357.05 Pasta dishes4.779.8
      6Pasta dishes3.760.76 Biscuits, cornbread, pancakes, tortillas4.484.2
      7Milk desserts3.063.77 Crackers, popcorn, pretzels, chips2.887.0
      8Biscuits, cornbread, pancakes, tortillas2.966.68 Milk drinks2.389.3
      9Eggs2.869.49 Bars/toaster pastries2.291.5
      10 Cheese2.772.1
      11 Crackers, popcorn, pretzels, chips2.674.7
      12 Cake, cookie, quick bread, pastry, pie2.577.2
      13 Poultry2.479.6
      14 Mixtures mainly meat2.181.7
      children/adolescents 9 to 18 years old
      Seven additional food groupings contributed at least 1% each to total dietary intake (in descending order: tortilla, taco mixtures; beef; frankfurters, sausages, luncheon meats; pork, ham, bacon; granola/cereal bars, toaster pastries; fruit juice; soup, broth, bouillon). Two additional food groupings contributed at least 1% each to added nutrient intake (in descending order: other nonalcoholic beverages; mixtures mainly meat, poultry, fish).
      (n=4,649)
      1Milk18.818.81Ready-to-eat cereal40.640.6
      2Ready-to-eat cereal12.231.02Yeast bread, rolls13.253.8
      3Pizza, turnovers7.938.93Pizza, turnovers12.566.3
      4Yeast bread, rolls6.945.84Cake, cookie, quick bread, pastry, pie5.772.0
      5Milk drinks4.250.05Biscuits, cornbread, pancakes, tortillas4.476.4
      6Pasta dishes3.353.36Pasta dishes4.180.5
      7Sandwiches, bread mixtures3.256.57Bars/toaster pastries3.984.4
      8Cheese3.159.68Sandwiches, etc.3.087.4
      9Cake, cookie, quick bread, pastry, pie3.062.69Tortilla, taco mixtures2.389.7
      10 Biscuits, cornbread, pancakes, tortillas3.065.610 Crackers, popcorn, pretzels, chips2.291.9
      11 Mixtures mainly meat2.968.5
      12 Crackers, popcorn, pretzels, chips2.871.3
      13 Milk desserts2.874.1
      14 Eggs2.576.6
      15 Poultry2.378.9
      a From day 1 dietary recall; sample weights applied.
      b Table includes data for food groupings contributing ≥2% of intake for the nutrient.
      c Seven additional food groupings contributed at least 1% each to total dietary intake (in descending order: fruit juice; fruit; yogurt; sandwiches, bread mixtures; frankfurters, sausages, luncheon meats; soup, broth, bouillon; fruit drinks, ades). Two additional food groupings contributed at least 1% each to added nutrient intake (in descending order: sandwiches, bread mixtures; mixtures mainly meat, poultry, fish).
      d Seven additional food groupings contributed at least 1% each to total dietary intake (in descending order: tortilla, taco mixtures; beef; frankfurters, sausages, luncheon meats; pork, ham, bacon; granola/cereal bars, toaster pastries; fruit juice; soup, broth, bouillon). Two additional food groupings contributed at least 1% each to added nutrient intake (in descending order: other nonalcoholic beverages; mixtures mainly meat, poultry, fish).
      Table 10Top food sources of niacin (both intrinsic and added to foods) and top food sources of only added niacin in the diets of children, from National Health and Nutrition Examination Survey 2003-2006
      From day 1 dietary recall; sample weights applied.
      Table includes data for food groupings contributing ≥2% of intake for the nutrient.
      Food Sources of Both Intrinsic and Added NiacinFood Sources of Only Added Niacin
      Rank and food grouping%Cumulative %Rank and food grouping%Cumulative %
      children 2 to 8 years old
      Seven additional food groupings contributed at least 1% each to total dietary intake (in descending order: fruit juice; milk; fruit; milk drinks; tortilla, taco mixtures; hot breakfast cereal; granola/cereal bars, toaster pastries). Seven additional food groupings contributed at least 1% each to added nutrient intake (in descending order: granola/cereal bars, toaster pastries; other nonalcoholic beverages; sandwiches, bread mixtures; mixtures mainly meat, poultry, fish; soup, broth, bouillon; rice, cooked grains; tortilla, taco mixtures).
      (n=2,601)
      1Ready-to-eat cereal20.920.91 Ready-to-eat cereal51.651.6
      2Poultry10.431.32 Yeast bread, rolls10.462.0
      3Yeast bread, rolls7.739.03 Pizza, turnovers6.968.9
      4Mixtures mainly meat5.444.44 Pasta dishes5.174.0
      5Pizza, turnovers5.249.65 Cake, cookie, quick bread, pastry, pie4.878.8
      6Pasta dishes5.254.86 Biscuits, cornbread, pancakes, tortillas3.682.4
      7Crackers, popcorn, pretzels, chips4.559.37 Crackers, popcorn, pretzels, chips2.985.3
      8Biscuits, cornbread, pancakes, tortillas3.462.7
      9White potatoes2.965.6
      10 Cake, cookie, quick bread, pastry, pie2.868.4
      11 Frankfurters, sausages, lunch meats2.771.1
      12 Beef2.573.6
      13 Nuts, seeds2.576.1
      14 Pork, ham, bacon2.278.3
      15 Sandwiches, bread mixtures2.280.5
      16 Soup, broth, bouillon2.282.7
      children/adolescents 9 to 18 years old
      Four additional food groupings contributed at least 1% each to total dietary intake (in descending order: granola/cereal bars, toaster pastries; soup, broth, bouillon; fruit juice; fish/shellfish). Two additional food groupings contributed at least 1% each to added nutrient intake (in descending order: mixtures main meat, poultry, fish; rice, cooked grains).
      (n=4,649)
      1Ready-to-eat cereal13.513.51Ready-to-eat cereal37.037.0
      2Poultry9.422.92Yeast bread, rolls14.251.2
      3Yeast bread, rolls8.931.83Pizza, turnovers11.362.5
      4Mixtures mainly meat7.739.54Other nonalcoholic beverages6.068.5
      5Pizza, turnovers7.747.25Cake, cookie, quick bread, pastry, pie5.073.5
      6Beef4.952.16Pasta dishes4.177.6
      7Sandwiches, bread mixtures4.957.07Biscuits, cornbread, pancakes, tortillas3.981.5
      8Pasta dishes4.361.38Sandwiches, bread mixtures3.284.7
      9Crackers, popcorn, pretzels, chips4.065.39Bars/toaster pastries3.187.8
      10 Biscuits, cornbread, pancakes, tortillas3.068.310 Tortilla, taco mixtures2.490.2
      11 White potatoes2.971.211 Crackers, popcorn, pretzels, chips2.292.4
      12 Pork, ham, bacon2.874.0
      13 Frankfurters, sausages, lunch meats2.876.8
      14 Cake, cookie, quick bread, pastry, pie2.679.4
      15 Tortilla, taco mixtures2.581.9
      16 Other nonalcoholic beverages2.484.3
      17 Nuts, seeds2.486.7
      a From day 1 dietary recall; sample weights applied.
      b Table includes data for food groupings contributing ≥2% of intake for the nutrient.
      c Seven additional food groupings contributed at least 1% each to total dietary intake (in descending order: fruit juice; milk; fruit; milk drinks; tortilla, taco mixtures; hot breakfast cereal; granola/cereal bars, toaster pastries). Seven additional food groupings contributed at least 1% each to added nutrient intake (in descending order: granola/cereal bars, toaster pastries; other nonalcoholic beverages; sandwiches, bread mixtures; mixtures mainly meat, poultry, fish; soup, broth, bouillon; rice, cooked grains; tortilla, taco mixtures).
      d Four additional food groupings contributed at least 1% each to total dietary intake (in descending order: granola/cereal bars, toaster pastries; soup, broth, bouillon; fruit juice; fish/shellfish). Two additional food groupings contributed at least 1% each to added nutrient intake (in descending order: mixtures main meat, poultry, fish; rice, cooked grains).
      Table 11Top food sources of vitamin B-6 (both intrinsic and added to foods) and top food sources of only added vitamin B-6 in the diets of children, from National Health and Nutrition Examination Survey 2003-2006
      From day 1 dietary recall; sample weights applied.
      Table includes data for food groupings contributing ≥2% of intake for the nutrient.
      Food Sources of Both Intrinsic and Added Vitamin B-6Food Sources of Only Added Vitamin B-6
      Rank and food grouping%Cumulative %Rank and food grouping%Cumulative %
      children 2 to 8 years old
      Twelve additional food groupings contributed at least 1% each to total dietary intake (in descending order: pizza, turnovers; pork/ham/bacon; yeast bread, rolls; frankfurters, sausages, luncheon meats; sandwiches, bread mixtures; granola/cereal bars, toaster pastries; soup, broth, bouillon; nuts, seeds including butters/pastes; other nonalcoholic beverages; eggs; hot breakfast cereal; tortilla, taco mixtures). One additional food grouping contributed at least 1% each to added nutrient intake (milk drinks).
      (n=2,601)
      1Ready-to-eat cereal26.926.91 Ready-to-eat cereal90.590.5
      2Milk6.733.62 Bars/toaster pastries3.293.7
      3Fruit5.639.23 Other nonalcoholic beverages3.096.7
      4White potatoes5.644.8
      5Fruit juice5.250.0
      6Poultry4.754.7
      7Biscuits, cornbread, pancakes, tortillas3.358.0
      8Mixtures mainly meat3.361.3
      9Crackers, popcorn, pretzels, chips3.364.6
      10 Milk drinks3.167.7
      11 Pasta dishes2.870.5
      12 Beef2.272.7
      children/adolescents 9 to 18 years old
      Five additional food groupings contributed at least 1% each to total dietary intake (in descending order: granola/cereal bars, toaster pastries; nuts, seeds including butters/pastes; milk drinks; cake, cookies, quick bread, pastry, pie; eggs). One additional food grouping contributed at least 1% each to added nutrient intake (cake, cookies, quick bread, pie).
      (n=4,649)
      1Ready-to-eat cereal19.319.31 Ready-to-eat cereal77.777.7
      2White potatoes6.325.62 Other nonalcoholic beverages12.390.0
      3Mixtures mainly meat5.731.33 Bars/toaster pastries6.096.0
      4Poultry5.536.8
      5Milk4.741.5
      6Beef4.746.2
      7Crackers, popcorn, pretzels, chips4.150.3
      8Fruit juice3.754.0
      9Other nonalcoholic beverages3.557.5
      10 Pizza, turnovers3.360.8
      11 Sandwiches, bread mixtures3.264.0
      12 Fruit3.167.1
      13 Biscuits, cornbread, pancakes, tortillas2.869.9
      14 Pasta dishes2.672.5
      15 Pork, ham, bacon2.575.0
      16 Yeast bread, rolls2.277.2
      17 Tortilla, taco mixtures2.279.4
      18 Frankfurters, sausages, lunch meats2.181.5
      a From day 1 dietary recall; sample weights applied.
      b Table includes data for food groupings contributing ≥2% of intake for the nutrient.
      c Twelve additional food groupings contributed at least 1% each to total dietary intake (in descending order: pizza, turnovers; pork/ham/bacon; yeast bread, rolls; frankfurters, sausages, luncheon meats; sandwiches, bread mixtures; granola/cereal bars, toaster pastries; soup, broth, bouillon; nuts, seeds including butters/pastes; other nonalcoholic beverages; eggs; hot breakfast cereal; tortilla, taco mixtures). One additional food grouping contributed at least 1% each to added nutrient intake (milk drinks).
      d Five additional food groupings contributed at least 1% each to total dietary intake (in descending order: granola/cereal bars, toaster pastries; nuts, seeds including butters/pastes; milk drinks; cake, cookies, quick bread, pastry, pie; eggs). One additional food grouping contributed at least 1% each to added nutrient intake (cake, cookies, quick bread, pie).
      Table 12Top Food Sources of vitamin B-12 (both intrinsic and added to foods) and top food sources of only added vitamin B-12 in the diets of children, from National Health and Nutrition Examination Survey 2003-2006
      From day 1 dietary recall; sample weights applied.
      Table includes data for food groupings contributing ≥2% of intake for the nutrient.
      Food Sources of Both Intrinsic and Added Vitamin B-12Food Sources of Only Added Vitamin B-12
      Rank and food grouping%Cumulative %Rank and food grouping%Cumulative %
      children 2 to 8 years old
      Five additional food groupings contributed at least 1% each to total dietary intake (in descending order: biscuits, corn bread, pancakes, tortillas; poultry; yogurt; pork, ham, bacon; tortilla, taco mixtures). One additional food grouping contributed at least 1% to added nutrient intake (other nonalcoholic beverages).
      (n=2,601)
      1Milk26.526.51 Ready-to-eat cereal86.286.2
      2Ready-to-eat cereal21.748.22 Biscuits, cornbread, pancakes, tortillas5.691.8
      3Milk drinks6.654.83 Milk drinks4.396.1
      4Mixtures mainly meat5.660.4
      5Beef4.164.5
      6Cheese3.467.9
      7Frankfurters, sausages, lunch meats3.271.1
      8Pizza, turnovers3.274.3
      9Fish, shellfish3.177.4
      10 Pasta dishes2.880.2
      11 Eggs2.883.0
      12 Sandwiches, bread mixtures2.285.2
      13 Milk desserts2.287.4
      children/adolescents 9 to 18 years old
      Four additional food groupings contributed at least 1% each to total dietary intake (in descending order: milk desserts; pork, ham, bacon; poultry; biscuits, corn bread, pancakes, tortillas). Two additional food groupings contributed at least 1% each to added nutrient intake (in descending order: granola/cereal bars, toaster pastries; cake, cookies, quick bread, pastry, pie).
      (n=4,649)
      1Milk19.519.51 Ready-to-eat cereal74.574.5
      2Ready-to-eat cereal16.335.82 Other nonalcoholic beverages15.590.0
      3Beef9.645.43 Biscuits, cornbread, pancakes, tortillas5.895.8
      4Mixtures mainly meat5.550.9
      5Sandwiches, bread mixtures5.356.2
      6Pizza, turnovers5.261.4
      7Cheese4.065.4
      8Frankfurters, sausages, lunch meats3.769.1
      9Fish, shellfish3.772.8
      10 Other nonalcoholic beverages3.476.2
      11 Milk drinks3.279.4
      12 Eggs2.481.8
      13 Pasta dishes2.384.1
      14 Tortilla, taco mixtures2.386.4
      a From day 1 dietary recall; sample weights applied.
      b Table includes data for food groupings contributing ≥2% of intake for the nutrient.
      c Five additional food groupings contributed at least 1% each to total dietary intake (in descending order: biscuits, corn bread, pancakes, tortillas; poultry; yogurt; pork, ham, bacon; tortilla, taco mixtures). One additional food grouping contributed at least 1% to added nutrient intake (other nonalcoholic beverages).
      d Four additional food groupings contributed at least 1% each to total dietary intake (in descending order: milk desserts; pork, ham, bacon; poultry; biscuits, corn bread, pancakes, tortillas). Two additional food groupings contributed at least 1% each to added nutrient intake (in descending order: granola/cereal bars, toaster pastries; cake, cookies, quick bread, pastry, pie).
      Table 13Top food sources of zinc (both intrinsic and added to foods) and top food sources of only added zinc in the diets of children, from National Health and Nutrition Examination Survey 2003-2006
      From day 1 dietary recall; sample weights applied.
      Table includes data for food groupings contributing ≥2% of intake for the nutrient.
      Food Sources of Both Intrinsic and Added ZincFood Sources of Only Added Zinc
      Rank and food grouping%Cumulative %Rank and food grouping%Cumulative %
      children 2 to 8 years old
      Twelve additional food groupings contributed at least 1% each to total dietary intake (in descending order: milk desserts; tortilla, taco mixtures; pork, ham, bacon; cake, cookies, quick bread, pastry, pie; eggs; candy, sugars, and sugary foods; white potatoes; legumes; yogurt; biscuits, cornbread, pancakes, tortillas; nuts, seeds including butters/pastes; soup, broth, bouillon). One additional food grouping contributed at least 1% each to added nutrient intake (granola/cereal bars, toaster pastries).
      (n=2,601)
      1Ready-to-eat cereal18.518.51 Ready-to-eat cereal96.896.8
      2Milk12.430.9
      3Beef5.236.1
      4Pasta dishes4.740.8
      5Mixtures mainly meat4.745.5
      6Pizza, turnovers4.750.2
      7Milk drinks4.254.4
      8Cheese4.158.5
      9Poultry3.762.2
      10 Crackers, popcorn, pretzels, chips3.665.8
      11 Frankfurters, sausages, lunch meats3.269.0
      12 Yeast bread, rolls3.072.0
      13 Sandwiches, bread mixtures2.574.5
      children/adolescents 9 to 18 years old
      Nine additional food groupings contributed at least 1% each to total dietary intake (in descending order: milk drinks; cake, cookies, quick bread, pastry, pie; nuts, seeds including butters/pastes; milk desserts; white potatoes; candy, sugars, and sugary foods; eggs; legumes; biscuits, cornbread, pancakes, tortillas). Three additional food groupings contributed at least 1% each to added nutrient intake (in descending order: crackers, popcorn, pretzels, chips; granola/cereal bars, toaster pastries; meal replacements/supplements).
      (n=4,649)
      1Ready-to-eat cereal11.711.71 Ready-to-eat cereal95.095.0
      2Beef10.522.2
      3Milk8.030.2
      4Pizza, turnovers7.137.3
      5Mixtures mainly meat7.144.4
      6Sandwiches, bread mixtures5.249.6
      7Cheese4.454.0
      8Crackers, popcorn, pretzels, chips3.957.9
      9Pasta dishes3.861.7
      10 Yeast bread, rolls3.765.4
      11 Tortilla, taco mixtures3.769.1
      12 Poultry3.672.7
      13 Frankfurters, sausages, lunch meats3.275.9
      14 Pork, ham, bacon2.478.3
      a From day 1 dietary recall; sample weights applied.
      b Table includes data for food groupings contributing ≥2% of intake for the nutrient.
      c Twelve additional food groupings contributed at least 1% each to total dietary intake (in descending order: milk desserts; tortilla, taco mixtures; pork, ham, bacon; cake, cookies, quick bread, pastry, pie; eggs; candy, sugars, and sugary foods; white potatoes; legumes; yogurt; biscuits, cornbread, pancakes, tortillas; nuts, seeds including butters/pastes; soup, broth, bouillon). One additional food grouping contributed at least 1% each to added nutrient intake (granola/cereal bars, toaster pastries).
      d Nine additional food groupings contributed at least 1% each to total dietary intake (in descending order: milk drinks; cake, cookies, quick bread, pastry, pie; nuts, seeds including butters/pastes; milk desserts; white potatoes; candy, sugars, and sugary foods; eggs; legumes; biscuits, cornbread, pancakes, tortillas). Three additional food groupings contributed at least 1% each to added nutrient intake (in descending order: crackers, popcorn, pretzels, chips; granola/cereal bars, toaster pastries; meal replacements/supplements).

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      Biography

      L. A. Berner is a professor, Food Science and Nutrition Department, California Polytechnic State University, San Luis Obispo.
      D. R. Keast is president, Food & Nutrition Database Research, Inc, Okemos, MI.
      R. L. Bailey is a nutritional epidemiologist, Office of Dietary Supplements, National Institutes of Health, Bethesda, MD.
      J. T. Dwyer is a senior nutrition scientist, Office of Dietary Supplements, National Institutes of Health, Bethesda, MD, and a professor, Schools of Medicine and Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA.