Implications of US Nutrition Facts Label Changes on Micronutrient Density of Fortified Foods and Supplements 1 3

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1 The Journal of Nutrition Issues and Opinions Implications of US Nutrition Facts Label Changes on Micronutrient Density of Fortified Foods and Supplements 1 3 Michael I McBurney,* Sonia Hartunian-Sowa, and Nathan V Matusheski DSM Nutritional Products, Parsippany, NJ Abstract The US FDA published new nutrition-labeling regulations in May For the first time since the implementation of the Nutrition Labeling and Education Act of 1990, the Daily Value (DV) for most vitamins will change, as will the units of measurement used in nutrition labeling for some vitamins. For some food categories, the Reference Amounts Customarily Consumed (RACCs) will increase to reflect portions commonly consumed on a single occasion. These regulatory changes are now effective, and product label changes will be mandatory beginning 26 July This commentary considers the potential impact of these regulatory changes on the vitamin and mineral contents of foods and dietary supplements. Case studies examined potential effects on food fortification and nutrient density. The updated DVs may lead to a reduction in the nutrient density of foods and dietary supplements with respect to 8 vitamins (vitamin A, thiamin, riboflavin, niacin, vitamin B-6, vitamin B-12, biotin, and pantothenic acid) and 6 minerals (zinc, selenium, copper, chromium, molybdenum, and chloride), and have mixed effects on 2 vitamins where the amount required per serving is affected by chemical structure (i.e., form) (natural vitamin E compared with synthetic vitamin E and folic acid compared with folate). Despite an increased DV for vitamin D, regulations limit food fortification. The adoption of Dietary Folate Equivalents for folate labeling may lead to reductions in the quantity of folic acid voluntarily added per RACC. Finally, because of increased RACCs in some food categories to reflect portions that people typically eat at one time, the vitamin and mineral density of these foods may be affected adversely. In totality, the United States is entering an era in which the need to monitor dietary intake patterns and nutritional status is unprecedented. J Nutr 2017;147: Keywords: vitamins, fortification, nutrient density, Nutrition Facts panel, Daily Value, DV, Reference Dietary Intake, RDI, Reference Amount Customarily Consumed, RACC Introduction The Nutrition Labeling and Education Act of 1990 was one of the most important milestones in food legislation (1). To help consumers maintain healthy dietary practices, the FDA requires nutrition labeling of conventional foods (21 Code of Federal Regulations 101.9) (2) and dietary supplements (21 Code of Federal Regulations ) (3). The labeling of some nutrients 1 The authors reported no funding received for this study. This is a free access article, distributed under terms ( guidelines-and-policies/license/) that permit unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 2 Author disclosures: MI McBurney, S Hartunian-Sowa, and NV Matusheski are employed by DSM Nutritional Products, a manufacturer of vitamins and supplier to the food, dietary supplement, and pharmaceutical industries. There were no other conflicts of interest. 3 Supplemental Tables 1 3 are available from the Online Supporting Material link in the online posting of the article and from the same link in the online table of contents at *To whom correspondence should be addressed. michael.mcburney@ dsm.com. is mandatory, whereas for others it is voluntary. The label conveys nutrition information per serving, defined as the amount of food customarily consumed per eating occasion by a person [i.e., the Reference Amount Customarily Consumed (RACC) 4 ]. The percent Daily Value (DV) on a food label indicates the relative amount of a nutrient that a serving of food or dietary supplement contributes and its significance in a total daily diet (4). When the Nutrition Labeling and Education Act was first implemented, the DVs for most vitamins and minerals were based on Reference Dietary Intakes (RDIs) derived from the 1968 National Academy of Sciences RDAs (5). RDIs for several other nutrients were established in 1995 on the basis of Estimated Safe and Adequate Daily Dietary Intakes established by the National Academy of Sciences in 1980 or 1989 (6). After years without change, in 2016 the FDA updated the Nutrition Facts and Supplement Facts labels, replaced RDIs from Abbreviations used: DFE, Dietary Folate Equivalent; DV, Daily Value; RACC, Reference Amount Customarily Consumed; RDI, Reference Dietary Intake. ã 2017 American Society for Nutrition. Manuscript received January 10, Initial review completed February 2, Revision accepted April 11, First published online May 10, 2017; doi: /jn

2 TABLE 1 aged $4 y 1 DVs pre and post July 2018 for adults and children Nutrient Pre July 2018 Post July 2018 Change, % Vitamin A 5000 IU 900 μg RAE Vitamin C 60 mg 90 mg +50 Calcium 1000 mg 1300 mg +30 Iron 18 mg 18 mg 0 Vitamin D 400 IU 20 μg Vitamin E (natural) 30 IU 15 mg Vitamin E (synthetic) 30 IU 15 mg Vitamin K 80 μg 120 μg +50 Thiamin 1.5 mg 1.2 mg 220 Riboflavin 1.7 mg 1.3 mg 224 Niacin 20 mg 16 mg NE Vitamin B mg 1.7 mg 215 Folate 400 μg 400 μg DFE 6 0 Folic acid 400 μg 400 μg DFE Vitamin B μg 2.4 μg 260 Biotin 300 μg 30μg 290 Pantothenic acid 10.0 mg 5.0 mg 250 Phosphorus 1000 μg 1250 μg +25 Iodine 150 mg 150 mg 0 Magnesium 400 mg 420 mg +5 Zinc 15 μg 11μg 227 Selenium 70 mg 55 mg 221 Copper 2.0 mg 0.9 mg 255 Manganese 2.0 μg 2.3 μg +15 Chromium 120 μg 35μg 270 Molybdenum 75 mg 45 mg 240 Chloride 3400 mg 2300 mg 242 Potassium 3500 mg 4700 mg +34 Choline 550 mg 550 mg 0 1 Adapted from data in reference 7. DFE, Dietary Folate Equivalent; DV, Daily Value; NE, niacin equivalent; RAE, Retinol Activity Equivalent. 2 1 mg RAE = 1 mg retinol = 2 mg supplemental b-carotene = 12 mg b-carotene = 24 mg a-carotene = 24 mg b-cryptoxanthin. 3 1 mg vitamin D = 40 IU. 4 1mga-tocopherol (label claim) = 1 mg a-tocopherol = 1 mg RRR-a-tocopherol = 2 mg all-rac-a-tocopherol. 5 1 mg NE = 1 mg niacin = 60 mg tryptophan. 6 1 mg DFE = 1 mg naturally occurring folate = 0.6 mg folic acid. with more recent reference values for most vitamins and minerals (7), and changed the RACC for some products (8). With the finalization of labeling regulations (7, 8), the purpose of this article is to analyze the potential impact of changes to the RDIs and RACCs on nutrient content in a selection of foods and with consideration of nutrients intrinsic to a food as well as from enrichment and/or fortification. A fundamental assumption in this article is that nutrients added by enrichment or fortification may be affected by regulatory change but not those that are intrinsic to a food. FIGURE 1 Vitamin B-12 concentrations of select foods post July 2018 assuming the product composition is changed to maintain pre July 2018 Daily Values. (10 19% of the RDI per RACC) or excellent ($20% of the RDI per RACC) source claims for 13 vitamins and 11 minerals (9). In addition, changes from International Units on the nutrition label for vitamins A, D, and E and the adoption of Dietary Folate Equivalents (DFEs) require food and supplement manufacturers to recalculate DV claims and possibly reformulate their products. Vitamin A is now expressed in Retinol Activity Equivalents (10), vitamin D in mg (11), and synthetic and natural forms of vitamin E are labeled according to the 2000 DRIs (12), where 1 mg a-tocopherol = 1 mg R,R,R-a-tocopherol or 2 mg all-raca-tocopherol. The adoption of DFEs from the 1998 DRIs (13) requires labeling 0.6 mg folic acid as 1 mg DFE. Assessment of the Impact on Nutrient Density Nutrient values are derived from the International Life Sciences Institute North America Nutrient Database. Exponent, Inc., developed a database, Database of Fortification, Enrichment, and Intrinsic Nutrient Levels in Foods Reported Consumed in What We Eat in America, NHANES and , version 1.0 (completed 16 October 2015), under contract with the Fortification Committee of the International Life Sciences Institute North America. Some values for folate and folic acid contents of foods are from the USDA National Nutrient Database for Standard Reference (release 28; released September 2015, slightly revised May 2016). Food codes, long descriptions of foods, Background on the Regulatory Changes Effective 26 July 2018, the RDI has been reduced for 8 vitamins and 6 minerals, increased for 3 vitamins and 5 minerals, and the impact will depend upon chemical structure (i.e., form) for 2 vitamins (Table 1). The most extreme changes occurred with vitamin D, increasing from 400 IU (10 mg) to 20 mg (a100% increase), and biotin, decreasing from 300 to 30 mg (90% decrease). These changes in RDIs fundamentally influence the nutrient quantity needed per RACC (nutrient density) for good FIGURE 2 Vitamin D concentrations of select foods and good source claims with the use of pre July 2018 and post July 2018 Daily Values. The horizontal lines represent good source claim amounts, as defined in reference McBurney et al.

3 TABLE 2 Regulations permitting the addition of vitamin D to food products 1 Category Regulatory reference Vitamin D 2 (levels not to exceed) Breakfast cereals 170.3(n)(4) 350 IU/100 g Grain products and pastas IU/100 g Milk IU/100 g Milk named using a nutrient content claim IU/100 g Milk products IU/100 g 100% Fruit juices IU D 3 /240 ml Meal-replacement beverages (powder or liquid) IU D 3 /240 ml (prepared beverage) Meal-replacement bars IU D 3 /40 g Cheese and cheese products IU D 3 /30 g Meal-replacement beverages (prepared) IU D 3 /240 ml Enteral nutrition products IU D 3 /100 g (800 IU/quart) BakerÕs yeast IU D 2 /100 g finished food Edible plant-based beverages intended as milk alternatives IU D 2 /100 g Edible plant-based yogurt alternatives IU D 2 /100 g Soy beverage products IU D 2 /100 g Soy-based butter substitute spreads IU D 2 /100 g Soy-based cheese substitutes and soy-based cheese substitute products IU D 2 /100 g 1 Adapted from data in 21 CFR in the electronic Code of Federal Regulations ( cited 12 Dec 2016). D 2, vitamin D 2 (ergocalciferol); D 3, vitamin D 3 (cholecalciferol) IU = 1 mg vitamin D. RACCs, and information to access these databases with intrinsic and added micronutrient values are available in Supplemental Tables 1 3. The foods selected reflect a range of food categories with differing levels of intrinsic and added nutrient contents. The intrinsic nutrient content of a food product does not change because of a regulatory update. However, food and supplement manufacturers may modify product compositions to attain post July 2018 DV claim levels (Table 1). For nutrients with an increased RDI (e.g., vitamin C, calcium, vitamin D, synthetic vitamin E, vitamin K, phosphorus, magnesium, manganese, and potassium), manufacturers will have to add more nutrients per RACC to maintain pre July 2018 DV claims. For the 14 nutrients with a reduced RDI (e.g., vitamin A, natural vitamin E, the B vitamins, zinc, selenium, copper, chromium, molybdenum, and chloride), products will show a greater percent DV, even though nutrient content per RACC (i.e., nutrient density) remains static. In fact, manufacturers may opt to reduce the amount of nutrients added post July 2018 (i.e., defortify, to maintain percent DV values closer to the pre July 2018 percent DV). The greatest percentage decreases in RDIs occurred with the B vitamins. The RDI for biotin has changed from 300 to 30 mg, a 90% reduction. Vitamin B-12 follows with a 60% reduction. Vitamin B-12, along with folate, is essential for brain development and function, so potential changes in the nutrient density of vitamin B-12 were examined. With a 60% reduction in RDI, vitamin B-12 fortification could be significantly reduced while pre July 2018 DV declarations are maintained (Figure 1). A similar scenario exists for every nutrient with a lower RDI. Vitamin D, a shortfall nutrient of public health concern, had a doubling in RDI. There are few foods intrinsically rich in vitamin D. A serving of canned salmon is one example, providing 15 mg vitamin D/RACC (85 g). Of 10 foods selected for this analysis, 6 have a vitamin D content of $1.0 mg/100 g (40 IU/100 g). Assuming a 100-g RACC, these 6 can be currently marketed as a good sources of vitamin D (10% of 400 IU DV). Because of the new 20-mg DV requirement post July 2018 (Figure 2), only 1 of these foods would remain with a good source claim (10% DV). Although the FDA has recently expanded the use of ergocalciferol (vitamin D 2 ) in some food categories and allowed a higher level of cholecalciferol (vitamin D 3 ) in milk (Table 2), laws limiting the addition of vitamin D to foods should be reviewed. For example, the vitamin D content of TABLE 3 Regulations permitting the addition of vitamin D to #350 IU/100 g (8.75 mg/100 g) and % DV claims in the breakfast cereal category 1 RACC Pre July Post July Maximum IU/RACC % DV claim 4 Maximum mg/racc % DV claim 4 15 g 52.5 Good source 1.31 No claim 40 g 140 Excellent source 3.5 Good source 60 g 210 Excellent source 5.25 Excellent source 1 RACC values are adapted from data in reference 8; % DV claims are adapted from data in reference 9. DV, Daily Value; RACC, Reference Amount Customarily Consumed. 2 DV = 400 IU (10 mg). 3 DV = 20 mg. 4 $10% DV = Good source; $20% DV = Excellent source. Updated RDIs, RACCs, and micronutrient density 1027

4 TABLE 4 Regulations permitting the addition of folic acid to food products 1 Category Regulatory reference Folic acid (levels not to exceed) Calculated SI equivalency Breakfast cereals μg/serving 2 Corn grits mg/lb 0.22 mg/100 g Meal-replacement products μg/13 serving daily 400 μg/240 ml Meal-replacement products μg/23 servings daily 200 μg/240 ml Corn masa flour mg/lb 0.15 mg/100 g Enriched flour mg/lb 0.15 mg/100 g Enriched self-rising flour mg/lb 0.15 mg/100 g Enriched corn meals mg/lb 0.22 mg/100 g Enriched farina mg/lb 0.19 mg/100 g Enriched macaroni and noodle products mg/lb 0.26 mg/100 g Enriched nonfat milk macaroni products mg/lb 0.26 mg/100 g Enriched noodle products mg/lb 0.26 mg/100 g Enriched bread, rolls, and buns mg/lb 0.09 mg/100 g Enriched rice mg/lb 0.31 mg/100 g 1 Category, regulatory reference, and folic acid data adapted from data in 21 CFR in the electronic Code of Federal Regulations ( gov; cited 12 Dec 2016). lb, pound; SI, International System. 2 Serving sizes are defined as 15, 40, or 60 g. Adapted from data in reference 8. breakfast cereals cannot exceed 350 IU vitamin D/100 g (8.75 mg vitamin D/100 g); therefore, fewer breakfast cereals will be good or excellent sources of vitamin D post July 2018 (Table 3). Regulations mandating folic acid enrichment or allowing the addition of folic acid to many foods similarly restrict amounts of folic acid in these food products (Table 4). With the adoption of the Institute of Medicine DFEs for labeling purposes (13), ambiguity has been introduced. Food manufacturers are required to add quantities of folic acid (micrograms) to meet enrichment and fortification regulations (Table 4). Pre July 2018, a nutrition label and DV was expressed as mg folic acid or folate/serving. Nutrition labels must be expressed as mg DFE post July 2018 (Table 1). By adopting DFEs for nutrition labeling, food and supplement manufacturers must start converting micrograms of folic acid added to a food to DFEs when creating a product nutrition label post July As nutrition labels are updated to meet post July 2018 regulations, the amount (in micrograms) of folic acid needed in a food to maintain a pre July 2018 DV can be reduced (Figure 3). Changes to folate labeling on prenatal supplements may have serious implications for pregnant women. The RDI of folate for pregnant and lactating women has been lowered from 800 mg folate (of which folic acid was considered as a 1:1 equivalent) to 600 mg DFEs (i.e., 600 mg folate or 360 mg folic acid). As such, the folic acid content of prenatal supplements meeting the 100% DV may be reduced by 55%. Before July 2018, a dietary supplement meeting the 100% DV for folate would contain 800 mg folic acid, labeled by using a 1:1 equivalency with folate. Post July 2018, 100% DV will require 600 mg DFEs and therefore only 360 mg folic acid (600 DFEs), less than the mg folic acid recommended as a daily dietary supplement for the prevention of neural tube defects (14). The RDI for vitamin E was lowered and anchored to 15 mg R,R,R-a-tocopherol (12). Synthetic (all-rac) forms contain half the activity of the naturally occurring R,R,R-a-tocopherol form. The percent DV on a food or supplement label will vary by vitamin E form (Table 1). Foods were not analyzed because of a lack of information on the form of vitamin E (i.e., synthetic compared with natural) added to foods. The biggest impact post July 2018 is expected in dietary supplements where capsules containing synthetic vitamin E will be ;2 times larger than those containing natural vitamin E to provide the same percent DV (Table 5). The changes to the RDIs, in terms of absolute values and measurement units, will affect the nutrient density of foods and supplements. Impact of New RACCs In addition to the RDI changes, serving sizes have been updated for some product categories to more realistically reflect the amount people typically eat at one time (8). By increasing the RACC from 55 to 110 g for the category of bagels, toaster pastries, and muffins (excluding English muffins), the amount of vitamin and mineral required per serving, or calories, to make a nutrient content claim is effectively halved (9). In the ready-to-eat cereal category (Table 3), the concentrations of vitamins and minerals (quantity per 100 g or kcal) in a breakfast cereal with a 60-g RACC is one-quarter of those with a 15-g RACC, even though both may carry a good source claim. As an example, the potential impact of changes in RACCs on micronutrient DVs is presented by using the fortified orange juice category (Table 6) assuming pre July 2018 formulations are adjusted to maintain the same vitamin and mineral percent DVs according to new container-specific regulations (i.e., multi-serving FIGURE 3 Combined folate and folic acid concentrations of select foods post July 2018 assuming the product composition is changed to maintain pre July 2018 Daily Values McBurney et al.

5 TABLE 5 Pre July 2018 (30 IU) and post July 2018 (15 mg a-tocopherol) calculations for nutrition labeling by source of vitamin E 1 Pre July 2018 Post July 2018 Form IU/mg mg R,R,R-a-tocopherol/mg Form Synthetic dl-a-tocopheryl acetate dl-a-tocopheryl acetate dl-a-tocopheryl succinate dl-a-tocopheryl succinate dl-a-tocopherol dl-a-tocopherol Natural d-a-tocopheryl acetate d-a-tocopheryl acetate d-a-tocopheryl succinate d-a-tocopheryl succinate d-a-tocopherol d-a-tocopherol 1 Adapted from data in reference 12. container compared with 20-fluid-ounce single-serving packaging). Many manufacturers use batch processing, which can be coupled to specific container size. Thus, the same product, even brand, can be produced with differing amounts of added vitamins and minerals per RACC, changing nutrient density. Depending on the serving container, an orange juice that is an excellent source of calcium may provide 110, 165, or 275 kcal/serving customarily consumed. To rephrase, consuming two and a half 8-ounce (240-mL) containers may provide the same amount of energy (kilocalories) as one 20-fluid-ounce (600-mL) single-serving container but provide 2.5 times more calcium, magnesium, potassium, vitamins D and C, thiamin, niacin, vitamin B-6, and folate. Substantial differences in nutrient density [i.e., amount of vitamins consumed per fluid ounce (milliliter) or kilocalories] affect micronutrient intake. A breakfast cereal with a 60-g RACC that is fortified to provide 10% DV of 8 vitamins and minerals is less nutrient dense (i.e., contains fewer vitamins and minerals per kilocalorie or per gram) than a breakfast cereal with a 30-g RACC containing 10% DV for 8 vitamins and minerals. Because RACCs of some categories (e.g., juices) vary with container size (Table 6), a consumer cannot expect a product with a specified nutrient content claim, or even a brand, to contribute the same amount of vitamins and minerals to their diet. To be nutritionally accurate, dietary record keeping will need to include product category, brand, and RACC. Conclusions Nutrition labeling is used by consumers to determine the nutrient content of a particular product and to compare different foods or products (15). The consumption of foods with added vitamins and minerals has reduced the risk of rickets (vitamin D), goiter (iodine), neural tube defects (folic acid), anemia (iron), beriberi (thiamin), pellagra (niacin), and riboflavin deficiency (16). Nevertheless, several nutrients are still underconsumed such as vitamins A, D, E, and C; calcium; magnesium; choline; potassium; dietary fiber; and iron by adolescent girls and women aged y (17). Changes in the consumption patterns of enriched and fortified foods and the use of dietary supplements affect the dietary intake of a population (18, 19). Fortified and enriched foods are important contributors of essential nutrients to the diet and help reduce shortfalls in nutrient intakes (18, 20). The assumptions used to derive the RDIs and the resulting DVs can have profound effects on micronutrient adequacy, especially in vulnerable subpopulations (5). Post July 2018, the updated DVs may lead to a reduction in nutrient density of fortified foods and dietary supplements with respect to 8 vitamins and 6 minerals. It is probable that intakes of vitamin A and the B vitamins will decrease post July Despite an increased DV for vitamin D, the maximum amount of vitamin D permitted in foods constrains vitamin D intake from food sources. The adoption of TABLE 6 Possible impact of changes in RACCs on nutrient density of a calcium- and vitamin D fortified orange juice 1 Pre July Post July Serving container [8 fl oz (240 ml)] 7-Serving container [8 fl oz (240 ml)] Single-serving container 12 fl oz (360 ml) 20 fl oz (600 ml) Energy, kcal Calcium, % DV Magnesium, % DV Potassium, % DV Vitamin D (D 2 +D 3 ), % DV Vitamin C, % DV Thiamin, % DV Niacin, % DV Vitamin B-6, % DV Folate DFE, % DV Adapted from data in reference 8. DFE, Dietary Folate Equivalent; DV, Daily Value; D 2, vitamin D 2 (ergocalciferol); D 3, vitamin D 3 (cholecalciferol); fl oz, fluid ounce; RACC, Reference Amount Customarily Consumed. 2 Percent of DV pre July 2018 for adults and children $4 y (from reference 7). 3 Percent of DV post July 2018 for adults and children $4 y (from reference 7). Updated RDIs, RACCs, and micronutrient density 1029

6 DFE units for folate labeling may lead to reductions in the amount of folic acid voluntarily added per RACC. By increasing RACCs to reflect amounts people customarily consume, the nutrient density in the affected food categories may also decline. It is imperative to monitor the impact of these regulatory changes on dietary intake and nutritional status. Acknowledgments The authorsõ responsibilities were as follows MIM: wrote the manuscript and had primary responsibility for the final content; NVM and SH-S: helped create the figures and tables; and all authors: read and approved the final manuscript. References 1. Shank FR. The Nutrition Labeling and Education Act of Food Drug Law J 1992;47: US FDA. Nutrition labeling of food. Fed Regist 2016;2: US FDA. Nutrition labeling of dietary supplements. Fed Regist 2016;2: Trumbo PR. FDA regulations regarding iodine addition to foods and labeling of foods containing added iodine. Am J Clin Nutr 2016;104:864S 7S. 5. Murphy MM, Spungen JH, Barraj LM, Bailey RL, Dwyer JT. Revising the Daily Values may affect food fortification and in turn nutrient intake adequacy. J Nutr 2013;143: US Institute of Medicine. History of nutrition labeling. Examination of front-of-package nutrition rating systems and symbols: phase I report [Internet]. Washington (DC): National Academies Press; 2010 [cited 2017 Jan 1]. Available from: 7. US FDA. Food labeling: revision of the nutrition and facts labels. Fed Regist 2016;81: US FDA. Food labeling: serving sizes of foods that can reasonably be consumed at one eating occasion; dual-column labeling; updating, modifying, and establishing certain Reference Amounts Customarily Consumed; serving size for breath mints; and technical amendments. Fed Regist 2016;81: US FDA. Nutrient content claims for good source, high, and more. Fed Regist 1993;58: US Institute of Medicine. Dietary Reference Intakes for vitamin A, vitamin K, arsenic, boron, chromium, copper, iodine, iron, manganese, molybdenum, nickel, silicon, vanadium, and zinc: a report of the Panel on Micronutrients and the Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board, Institute of Medicine. Washington (DC): National Academies Press; US Institute of Medicine. Dietary Reference Intakes for calcium and vitamin D. Washington (DC): National Academies Press; US Institute of Medicine. Dietary Reference Intakes for vitamin C, vitamin E, selenium, and carotenoids. Washington (DC): National Academies Press; US Institute of Medicine. Dietary Reference Intakes for thiamin, riboflavin, niacin, vitamin B6, folate, vitamin B12, pantothenic acid, biotin, and choline. Washington (DC): National Academies Press; Bibbins-Domingo K, Grossman DC, Curry SJ, Davidson KW, Epling JW, García FAR, Kemper AR, Krist AH, Kurth AE, et al.; US Preventive Services Task Force. Folic acid supplementation for the prevention of neural tube defects: US Preventive Services Task Force recommendation statement. JAMA 2017;317: Guthrie JF, Fox JJ, Cleveland LE, Welsh S. Who uses nutrition labeling, and what effects does label use have on diet quality? J Nutr Educ 1995;27: Dwyer JT, Woteki C, Bailey R, Britten P, Carriquiry A, Gaine PC, Miller D, Moshfegh A, Murphy MM, Smith Edge M. Fortification: new findings and implications. Nutr Rev 2014;72: US Department of Health and Human Services and USDA DietaryGuidelinesforAmericans.8thed[Internet].c2015[cited2017Jan 10]. Available from: Fulgoni VL, Keast DR, Bailey RL, Dwyer J. Foods, fortificants, and supplements: where do Americans get their nutrients? J Nutr 2011;141: Wallace TC, McBurney M, Fulgoni VL III. Multivitamin/mineral supplement contribution to micronutrient intakes in the United States, J Am Coll Nutr 2014;33: Berner LA, Keast DR, Bailey RL, Dwyer JT. Fortified foods are major contributors to nutrient intakes in diets of US children and adolescents. J Acad Nutr Diet 2014;114: , e McBurney et al.