Table 1.
Overview of vitamin D fortification policies in European countries
| Country | Fortification policy/description | Ref. | Cat |
|---|---|---|---|
| Countries of the European Union (27 countries) | |||
| Austria | No mandatory fortification | [46] | — |
| Belgium | Mandatory: Margarines and spreadable fats (6–7.5 µg/100 g), voluntary: milk, dairy drinks, milk substitutes, cereals, biscuits, fruit juices, lemonades, cocoa powder, weight-loss products | [47] | − |
| Bulgaria | “Vitamin D food fortification is not mandatory (…) and there is virtually no fortified foodstuff on the market. Fish consumption is also low and we can assume that for the majority of the population the alimentary vitamin D intake is generally scarce.” | [48] | — |
| Croatia | “(…) despite the fact that the margarines are vitamin D fortified and some fortified dairy products are available, none of them contributes to [a] high vitamin D share in the diet.” | [49] | − |
| Cyprus | No mandatory fortification (corr. with Cypriotic Public Health Authority, Sept. 21, 2020) | − | — |
| Czech Republic | “Moreover, there is no mandatory and only minimal voluntary vitamin D food fortification in the Czech Republic.” | [50] | — |
| Denmark | Allowed, not mandatory, rarely done | [51] | − |
| Estonia | Allowed but not mandatory | [52] | − |
| Finland | Mass fortification of milk, margarine/fat spread; fortification of selected brands for yoghurt, orange juice, plant-based milk, bread, cereals1 | [53] | ++ |
| France | Allowed but not mandatory | [54] | − |
| Germany | No mandatory fortification + previously largely not allowed | [26] | — |
| Greece | No fortification policy | [55] | — |
| Hungary | “Because the typical Hungarian diet contains little vitamin D and food is not fortified, the vast majority of vitamin D is formed in the skin by ultraviolet-B (UVB) radiation.” | [56] | — |
| Ireland | Voluntary fortification of milk (~ 160 IU/200 ml) and cereals (~ 118 IU/35 g), mandatory fortification of margarine | [57, 58] | o |
| Italy | “(…) lack of appropriate fortification and supplementation of foods.” | [59] | — |
| Lithuania | No fortification (corr. with Ministry of Health, Sept. 14, 2020) | − | — |
| Luxembourg | No fortification (corr. with Ministry of Health, Oct. 20, 2020) | — | |
| Malta | No fortification policy; fortified yoghurt for children available (corr. with Maria Bonnici, Jan. 25, 2021). Since 2021 also fortified milk is available [60] | − | — |
| The Netherlands | No mandatory fortification; voluntary fortification previously allowed only for certain fats and oils, no more than 0.075 µg/g[61], now apparently also some cereals, dairy products and drinks are fortified with 30–650 IU/100 g [62] | [61, 62] | − |
| Poland | No fortification (except milk formulas for infants and toddlers) | [63] | — |
| Portugal | No fortification policy/no mandatory fortification, but some fortified foods such as yoghurts, milk, breakfast cereals, etc. are available in the market | [64, 65] | − |
| Spain | Fortification is voluntary for all foods except for infant formulas and infant cereals. Moreover, (…) there is a tendency to fortify skimmed and semi‐skimmed milks with vitamin D to reach the initial levels of whole milk; in addition, some commercial products are fortified with vitamin D such as biscuits, yoghurt, margarine, cheese, cereals and juices | [66] | − |
| Romania | “In Romania dietary sources of vitamin D are scarce and there is no fortification of food with vitamin D.” | [67] | — |
| Slovakia | No special legislation concerning fortification (vitamin D may be voluntary added to foods) (corr. with Slovakian Public Health Authority, Sept. 22, 2020) | − | — |
| Slovenia | “(…) dairy and other food products are generally not fortified with vitamin D (…).” | [68] | — |
| Sweden | Low-fat milk, fermented milk products, margarine | [69] | + |
| Non-EU countries with available data (6 countries) | |||
| Iceland | Low-fat milk, some imported foods (vegetable oils and cereals) | [70] | + |
| Norway | Largely prohibited, but voluntary fortification of extra low-fat milk and relatively high intake of cod liver oil and fish oil supplements | [71–73] | + |
| Serbia | No fortification policy | [74] | — |
| Switzerland | No mandatory fortification | [46] | — |
| Turkey | “25(OH)D fortified foods are not common in markets and their prices are higher when compared to the similar group of foods.” | [75] | — |
| UK | Margarine (not less than 7.05 µg and not more than 8.82 µg of vitamin D), infant formula and foods intended for use in energy-restricted diets, bread (200 IU/100 g), orange beverage (1000 IU/240 ml) | [62] | ++ |
IU international units; Ref. reference; Corr. correspondence; Cat. categorization into fortification level: ++ : mandatory fortification with adequate amounts covering adequate range of products; + : wide-spread voluntary fortification but with insufficient amounts or adequate mandatory fortification but with too few products, or other wide-spread sources of vitamin D intake; o: insufficient mandatory fortification plus some voluntary fortification, − : no mandatory fortification but commonly some voluntary fortification of foods; —: no mandatory fortification and in practice also almost no voluntary fortification of foods.; —?: unknown, supposedly no fortification. 1Amounts of vitamin D in fortified foods might, however, still be inadequate especially during the winter months, with daily uptakes from fortified foods of ~ 330–440 IU/day [76]. Note: no information could be obtained for Latvia, which was assumed to have no fortification. European countries not considered because of missing Eurostat data on cancer deaths (sorted by population size): Ukraine, Belarus, Moldova, Bosnia, Albania, Kosovo, Montenegro, Monaco, Liechtenstein, San Marino, Vatican City